Acute Liver Failure: Best Practice in Medical Management

The common etiologies of acute liver failure (ALF) include viral hepatitis, drugs, autoimmune and metabolic disorders, vascular causes and toxins.

Investigations performed in ALF include CBC, LFT, INR, blood sugar, serology (HAV, HCV, HEV, HBV), copper studies, autoimmune, ultrasound, ammonia (prognostic marker) and work up for ALF mimics. Patients with diabetes are at high risk of developing severe hepatitis and liver failure due to hepatitis virus infection. Hyperglycemia should be avoided. The blood sugar must be controlled.

Do not transfuse blood products prophylactically in patients with ALF, unless there is active bleeding. Thromboelastography is a good guide for transfusion of blood products. Feeding should be started as early as possible preferably via the enteral route. Nasogastric tube can increase the intracranial pressure because of gagging.

Nasogastric tube placement should generally be performed when the patient is sedated or intubated. Parenteral nutrition with lipid emulsions (omega-3/MCT) can be given if contraindications for enteral feeding.

Acute kidney injury (AKI) is common in patients with ALF. Renal replacement therapy (RRT) for ALF with AKI should be started as per standard indications (fl uid overload, hyperkalemia, metabolic acidosis, uremia). Continuous renal replacement therapy (CRRT) is preferred over intermittent hemodialysis as it is better tolerated with lower chances of raised ICT.

Patients with ALF are volume depleted and require crystalloid volume repletion. If hypotension persists, then noradrenaline should be administered. The ideal mean arterial pressure (MAP) is 60-70 mmHg. Higher MAP may be detrimental.

ALF patients also have respiratory issues. There is no role of prophylactic hyperventilation. Limited suctioning with instillation of lidocaine 1-2 mL, with prior 100% oxygen before suctioning to prevent acute surges in intracranial pressure.

Liver transplant should not be considered when the clinical status is improving or there are more than three organ failures (circulatory failure with the requirement of two vasopressors with limited response to further dose escalation and severe respiratory failure requiring maximal ventilator support or on extracorporeal membrane oxygenation).

Ongoing severe sepsis and tissue invasive fungal infection are relative contraindications of liver transplant; it can be considered after the infection has been controlled.

Available liver assist devices (artifi cial or bioartifi cial) have failed to either make an impact as a bridge to liver transplantation or improve transplant-free survival.