acute liver failure (ALF)
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Introduction
Acute liver injury with hepatic encephalopathy & coagulopathy in patients without hepatic cirrhosis.
Etiology
- drug/chemical toxicity
- acetaminophen toxicity (most common overall)
- antimicrobials are the second most common cause
- methylenedioxymethamphetamine (Ecstasy)
- mushroom poisoning
- bacillus cereus
- viral hepatitis:
- veno-occlusive disease, Budd Chiari syndrome
- Wilson's disease
- acute liver failure of pregnancy, HELLP
- Reye's syndrome
- autoimmune hepatitis
- hypotension -> hepatic hypoxia -> Diagonsis:
- King's College Criteria
- acetaminophen: pH < 7.30 + INR > 6.5, serum creatinine > 3.4 + encephalopathy
- non acetaminophen criteria as well
- King's College Criteria
Laboratory
- PT/PTT abnormal
- liver function tests may be abnormal
- plasma NH3 may be elevated
- serum acetaminophen (see acetaminophen poisoning)
- hepatitis serology
- hepatitis A serology
- hepatitis B serology
- hepatitis C serology
- serum creatinine
- complete blood count
- thrombocytopenia in 3rd trimester (HELLP)
- testing for Wilson's disease
- do NOT perform liver biopsy
- dangerous
- not associated with improved outcomes
Radiology
- CT of head if altered mental status to rule out cerebral edema or intracerebral hemorrhage[3]
Complications
- hepatic encephalopathy, cerebral edema
- coagulopathy
- hypoglycemia
- hypotension, distributive shock
- pulmonary edema
- nosocomial pneumonia
- acute renal failure (30-50%)
- death
Differential diagnosis
- acetaminophen poisoning
- hepatitis A infection: outbreaks associated with food
- hypoperfusion of the liver: acute hypotension during hospitalization
- Wilson's disease: young patient with psychiatric history &/or athetosis
- Herpes simplex or Herpes zoster: immunocompromised or pregnant[3]
Management
- N-acetylcysteine for drug-induced liver injury, including acetaminophen toxicity & other drugs (amoxicillin etc)
- specific treatment for specific etiology may be indicated
- fresh frozen plasma for coagulopathy
- arteriovenous hemofiltration with or without hemodialysis supports renal function
- lactulose for encephalopathy (see fulminant hepatic failure)
- referral to transplantation center for liver transplantation
- fulminant hepatic failure
- transplantation centers monitor intracranial pressure for cerebral edema due to hepatic encephalopathy
- mechanical liver assistance does not extend survival
- prognosis:
- drug-induced acute liver failure (excluding acetaminophen)
- 3-week survival without liver transplant is 27%[4]
- liver transplantation successful in 42%
- reduced liver transplantation & improved survival between 1998 & 2013[5]
- drug-induced acute liver failure (excluding acetaminophen)
More general terms
More specific terms
References
- ↑ Lee WM Acute liver failure N Engl J Med 1993, 329:1862 PMID: https://www.ncbi.nlm.nih.gov/pubmed/8505063
- ↑ O'Grady JG et al, Fulminant hepatic failure. In: Diseases of the Liver, Schiff L, Schiff R (eds), JB Lippincott, Philadelphia 1993
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 4.0 4.1 Reuben A et al. Drug-induced acute liver failure: Results of a U.S. multicenter, prospective study. Hepatology 2010 Dec; 52:2065. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20949552
- ↑ 5.0 5.1 Reuben A et al. Outcomes in adults with acute liver failure between 1998 and 2013: An observational cohort study. Ann Intern Med 2016 Apr 5 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27043883
- ↑ Lee WM, Stravitz RT, Larson AM. Introduction to the revised American Association for the Study of Liver Diseases Position Paper on acute liver failure 2011. Hepatology. 2012 Mar;55(3):965-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22213561 Free PMC Article