17. Management of acute liver failure Flashcards
What is acute liver failure?
Acute liver failure (ALF) is the acute deterioration of liver function in a patient without underlying chronic liver disease, characterized by two-to-three times elevation of transaminases
What are liver syndromes?
Liver syndromes are a group of symptoms and signs that indicate liver dysfunction, such as jaundice, coagulopathy, and hepatic encephalopathy.
What is acute-on-chronic liver failure?
Acute deterioration in liver function and extrahepatic organ failures in patients with chronic liver disease with high mortality rate.
What is are symptoms of decompensation of cirrhosis?
- Ascites,
- hepatic encephalopathy,
- renal impairment,
- GI bleeding.
What is the burden of ALF?
There is no clear incidence and prevalence, but it has a very bad prognosis without transplant
What is the classification of ALF based on the time interval between the onset of symptoms (jaundice) and the development of hepatic encephalopathy?
- hyperacute,
- acute,
- subacute,
- chronic liver disease.
What are the characteristics of hyperacute ALF?
- increased transaminase levels,
- severe coagulopathy,
- increase in bilirubin which usually precedes clinical encephalopathy.
What are some causes of hyperacute ALF?
- acetaminophen toxicity
- ischemic hepatopathy.
What are the characteristics of subacute/subfulminant ALF?
- milder increase in serum transaminases,
- deep jaundice,
- mild to moderate coagulopathy,
- splenomegaly,
- ascites,
- shrinking in liver volume
What is Wilson’s disease?
An inherited disease caused by inability to get rid of extra copper, causing copper accumulation in the liver, kidneys…
Other than hepatitis A-E, what viruses can cause hepatitis?
HSV, VZV, EBV, CMV, and adenovirus.
What is AFLP?
Acute fatty liver of pregnancy.
What are the etiological factors of acute liver failure with no pre-existing liver disease?
- autoimmune hepatitis,
- Budd-Chiari syndrome,
- Wilson’s disease,
- hepatitis B infection.
What are danger-associated molecular patterns (DAMPs)?
Molecules released by damaged cells that can trigger an immune response, and leads to organ failure (and death)
What are some complications of acute liver failure?
- CNS disturbances (hepatic encephalopathy, cerebral edema, seizures),
- infections,
- coagulopathy and bleeding,
- renal failure,
- metabolic derangement.
What are the diagnostic methods for acute liver failure?
- History taking,
- clinical signs,
- physical examination of liver and spleen,
- lab results (blood/urine),
- imaging (abdominal US, CT, MRI, Fibroscan/elastography, endoscopy, echocardiography),
- histology (liver biopsy).
What are the symptoms of acute liver failure?
- Jaundice,
- Right upper quadrant pain,
- nausea, vomiting,
- pruritus,
- fatigue, malaise,
- melena/hematemeses.
- mental confusion, difficulty concentrating
What are some physical findings associated with hepatic encephalopathy?
- Icterus (sclera, mucosa, skin),
- neurological signs (flapping tremor, consciousness),
- right upper quadrant tenderness,
- hepatomegaly,
- skin bleedings (petechia, purpura, ecchymosis, suffusion),
- ascites,
- hernias (umbilical, scrotal, inguinal).
What are the laboratory markers used for hepatic encephalopathy?
- AST/GOT,
- ALT/GPT (hepatocellular)
- GGT,
- ALP (alkaline phosphatase)
- total blood count,
- LDH,
- full coagulation screen
- bilirubin, ammonia, albumin, glucose (amylase, lipase)
- arterial blood gas and lactate
- toxicology screen in urine
- paracetamol serum level
- serum pregnancy test
- viral serology, immune markers, Cu markers.
What are the diagnostic criteria for hepatic encephalopathy?
- Prolongation of prothrombin time (INR) ≥ 1.5
- Any degree of hepatic encephalopathy
- No prior evidence of liver diseases
- Disease course of ≤26 weeks.
What is the most common cause of Budd-Chiary syndrome?
Blood clots in the hepatic veins.
What are the indications of liver biopsy?
- To distinguish alf from chronic liver disease
- no exact etiology based on laboratory and imaging tests
What is the course of treatment for acute liver failure?
- Specific treatment is given to treat the underlying cause,
- Supportive care
- Patients must be managed in ICU
What are some characteristics of acute liver failure, such as necrosis and bleeding?
Acute liver failure is characterized by extensive hepatocellular necrosis and sinusoidal bleeding.
What is the specific therapy for autoimmune hepatitis?
Glucocorticoids with careful consideration of infection risk.
What is the management for Amanita phalloides poisoning?
- Gastric aspiration, lavage
- activated charcoal,
- silibinin,
- penicillin G,
- N-acetylcysteine.
What are the treatment options for Budd-Chiari syndrome?
Transjugular intrahepatic shunt placement, surgical decompression, thrombolysis.
What is the recommended treatment for acetaminophen intoxication?
N-acetylcysteine.
What kind of supportive therapy is given for ALF?
- Haemodynamic stabilisation (fluids, vasopressorsà
- Ventilatory support
- Renal replacement therapy
- Broad spectrum antibiotics for infections
What is the recommended treatment for hepatic encephalopathy in patients with liver cirrhosis?
Lactulose and rifaximin, although rifaximin is controversial.
What are some metabolic abnormalities that can occur in patients with liver cirrhosis?
- Acidosis,
- hypokalaemia,
- hyponatraemia,
- hypophosphataemia,
- hypoglycaemia.
What are some coagulation abnormalities that can occur in patients with liver cirrhosis?
- Diminished synthesis of coagulation factors,
- reduction of platelet count and abnormal platelet function,
- increased risk of hypercoagulability.
What are some examples of haemoderivates that can be administered before invasive procedures in patients with liver cirrhosis?
Fresh frozen plasma, protrombin complex, cryoprecipitate, and thrombocyte replacement.
What percentage of ALF patients suffer from intracranial hypertension?
50%.
What are the supportive management techniques for intracranial hypertension?
- Elevation of patient’s head at 30 degrees,
- Valsalva manoeuvres,
- proper sedation,
- strict monitoring of serum sodium level,
- mannitol (strict monitoring!)
What is the purpose of MARS in supportive management of acute liver failure?
MARS uses albumin dialysis to eliminate inflammatory molecules, but it has no survival benefit.
What is the purpose of HepaAssist in supportive management of acute liver failure?
HepaAssist uses porcine hepatocytes, but it has no survival benefit.
What is the purpose of high-volume plasma exchange in supportive management of acute liver failure?
High-volume plasma exchange eliminates toxic molecules and cytokines, by exchanging plasma with fresh frozen plasma
What is the most important intervention to improve survival in most severe cases of acute liver failure?
Liver transplantation
What are the 1- and 5-year survival rates for liver transplantation in severe cases of acute liver failure?
The 1- and 5-year survival rates for liver transplantation in severe cases of acute liver failure are 84% and 75%, respectively, which are lower than non-ALF indications.
What is the mechanism of action of hepatocyte transplantation?
The transplantation of functional hepatocytes to replace damaged or lost liver cells.
What are the future directions for treating acute liver failure?
Cell transplantation, including hepatocyte and stem cell transplantation, and organ engineering using decellularized 3D extracellular matrix.
What are the King’s college criteria for diagnosing paracetamol-induced acute liver failure?
- Arterial pH < 7.3
- lactate > 3 mmol/L,
- serum creatinine > 300 μmol/L, or INR > 6.5.
What are the King’s college criteria for diagnosing non-paracetamol-induced acute liver failure?
- INR > 6.5
- or 3 out of the 5 following criteria: aetiology: “indeterminate”, age 40, icterus-HE interval > 7 days, bilirubin > 300 μmol/L, and INR > 3.5.
What is donor liver steatosis?
Donor liver steatosis refers to the accumulation of fat in the liver of a potential donor, which can increase the risk of complications after liver transplantation.
