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Adult Therapeutics Handbook

Management of Acute Liver Failure

Management of Acute Liver Failure

Definition of Acute Liver Failure: Encephalopathy developing in a person with acute hepatic dysfunction within 8 weeks of the onset of jaundice.

Introduction

  • Most acute admissions for liver failure occur in patients with pre-existing liver disease.
  • Acute liver failure strictly refers to those patients without such a history, and is much rarer.
  • The guidelines, Acute Liver Failure and Management of Decompensated Liver Disease, are intended to help with both the acute case and with the deterioration of chronic cases.

Aetiology

The causes of acute liver failure in the UK are, in order of incidence:

  • Paracetamol overdose (70%)
  • Viral Hepatitis (8.4%)
  • Idiosyncratic drug reaction (5.1%)
  • Budd-Chiari (2.1%)
  • Autoimmune (2%)
  • Ischaemic (2%)
  • Miscellaneuous (10.4%)

(Reference: Edinburgh Royal Infirmary 2009)

Clinical features

  • Encephalopathy
  • Jaundice: may be minimal in early stages
  • Hepatic foetor
  • Liver size: normal or small. Large liver suggest chronicity
  • Metabolic acidosis and renal failure may be early and marked in paracetamol overdose
  • Coagulopathy
  • Hypoglycaemia
  • Infection
  • Circulatory collapse

Assessment / monitoring

  • Immediate: FBC, coagulation screen, blood glucose, U&Es, paracetamol levels, blood and urine cultures.
  • Urgent (within 24 hours): LFTs, hepatitis serology (IgM anti-HAV, HBsAg, IgM anti-HBc and anti-HCV).
  • Chest x-ray, ultrasound (US) of liver and pancreas.

Consider:

  • Serum caeruloplasmin, 24 hour urinary copper, Kayser Fleischer rings to be assessed by Ophthalmologist for Wilson’s disease.
  • Doppler US of hepatic vein if Budd-Chiari suspected.
  • EEG if doubt about the aetiology of cerebral dysfunction.

General management and treatment options

Seek senior help early. ITU admission will be required for all grades of encephalopathy in the acute patient. Your consultant should be aware of the patient on the day of admission so that early discussions can take place with relatives and the Liver Transplant Unit if needed.

General

  • Monitor urine output hourly, blood glucose every 2 hours.
  • Do not sedate
  • Avoid arterial puncture (except in paracetamol overdose where a lactate level provides important prognostic information).

Encephalopathy

  • If Grade II or worse on presentation, and cerebral oedema is suspected, nurse 20 - 300 head elevated and give mannitol IV 20%, 0.5g/kg over 30 - 60 minutes and repeat 4 hourly if necessary.

Hypoglycaemia

  • Glucose IV 10% at a rate of 100ml/hour. For profound hypoglycaemia see guideline on Management of Hypoglycaemia.
  • Continuous infusion of glucose may cause hyponatraemia which may itself be a contraindication to liver transplantation. Therefore the recommendation is to give concurrent:
    • sodium chloride IV 0.9% plus
    • potassium chloride IV 40mmol/L if hypokalaemic.

Coagulopathy

  • Do not give blood products (i.e. fresh frozen plasma, factor concentrates) unless bleeding is a problem.
  • Vitamin K (Phytomenadione) does not correct clotting defect but give Phytomenadione 10mg slow IV bolus over 3 - 5 minutes to ensure patient is replete.

If bleeding occurs

  • Discuss with Haematologist
  • Take blood for FDPs or D-Dimers to exclude DIC (disseminated intravascular coagulation).
  • Give fresh frozen plasma.
  • Consider platelets 6units if platelets <20x109/L.

Sepsis

  • Culture blood and urine at baseline and every 24 hours.

Renal failure

  • If K+ > 6mmol/L, HCO3- <15mmol/L or creatinine >400micromol/L, the patient will need renal support. Discuss with the Renal unit regarding modality.

Indication for discussion with the Scottish Liver Transplant Unit in Acute Liver Failure

Rather than waiting until the strict criteria for transplantation are met, patients with severe acute liver failure should be discussed with the Scottish Liver Transplant Unit (see Appendix 6 for contact details) at an early stage. This should occur if:

  • Prothrombin time >30 seconds or INR >2.5
  • pH <7.3 or H+ >50nmol/L
  • Hypoglycaemia
  • Encephalopathy (note encephalopathy may progress rapidly and often manifests as initial mild confusion / disorientation).
  • Creatinine >200micromol/L
  • Raised lactate

Indications for transplant

The following outlines current indications for transplantation but by the time the patient fulfills the criteria he/she should already be in a liver unit.

Paracetamol overdose modified Kings (with lactate)

  • Strongly consider listing for transplantation if arterial lactate >3.5mmol/L after early fluid resuscitation (4 hours).
  • List for transplantation if arterial pH <7.3 or arterial blood lactate >3mmol/L after adequate fluid resuscitation (12 hours).
  • List for transplantation if all three of the following occur within a 24 hour period: creatinine >300micromol/L, PT >100 seconds (INR >6.5), grade ¾ encephalopathy.