Acute liver Failure

Question 1

Criteria for acute liver failure.

Answer 1

Encephalopathy
Coagulopathy INR ≥ 1.5
No pre-existing liver disease
Illness < 26 weeks

Question 2

Features of Hyperacute LF.

Answer 2

0-1 week for time from jaundice to encephalopathy.
3+ coagulopathy
1+ Jaundice
3+ ICP Hypertension and oedema

Question 3

Causes of Hyperacute LF

Answer 3

Paracetamol OD
Hepatitis A and E
Ischaemic Hepatitis,

Question 4

Causes of Acute LF

Answer 4

Acute Hepatitis B

Question 5

Causes of subacute lF

Answer 5

Idiosyncratic DILI
Cryptogenic

Question 6

Early diagnosis of ALF- what do you do

Answer 6

INR> 1.5
Mentation is altered
No pre-existing Liver DIsease.

Cerebral oedema: IVI mannitol prior transfer
IVI Dextrose in saline to maintain glucose
Intubation?

Question 7

what are the risk factors that causes raised Intercranial Pressure and cerebral oedema?

Answer 7

Hyperacute > acute > subacute ALF
Serum ammonia > 150 – 200 mol/l
Clinical correlate of HE (grade 3/4 encephalopathy)
- 25-35% in grade 3 and 65-75% grade 4
Need for vasopressors or renal replacement therapy
Presence of infection +/or SIRS

Question 8

Describe the presentation of Paracetamol-induced ALF.

Answer 8

Nausea
Vomiting
RUQ pain

Question 9

Investigation results for PIALF

Answer 9

pH 7.32 and Lactate 2,0

Tbil 29 CBil 18
ALT 1378 AST 1567
GGT 145 ALP 125

Hb 12.4 WCC 18 Platelets 213
INR 1.7

Question 10

Management of Paracetamol Hepatotoxicity

Answer 10

N-Acetyl cysteine
Recommended in any case of ALF where paracetamol toxicity is suspected
NAC replenishes glutathione stores; improves systemic and cerebral haemodynamics and oxygen delivery/consumption
Give as early as possible
DO NOT WAIT FOR PARACETAMOL LEVELS
Effective even >48 hrs after ingestion

IVI NAC administration
Loading dose 150mg/kg in 5% dextrose over 15 min
50mg/kg over 4 hrs
Then 100mg/kg over 16 hrs
Continue maintenance dose (100mg/kg as a continuous 24 hr infusion) until reversal of synthetic dysfunction or Transplant

Question 11

Herpes Simplex hepatitis

Answer 11

3 day history of severe headache, fever, nausea and RUQ discomfort.
Investigations

TBil 32 CBil 29
ALT 3150 AST 3982
ALP 180 GGT 76
Ammonia 95
INR 3.2
Viral serology
Hepatitis B : HBsAg and HB IgM core Ab negative
Hepatitis A : IgM Ab negative
Hepatitis C : HCV Ab negative
Herpes simplex: HSV PCR positive

Acute Herpes Simplex Hepatitis
Do you wait until these results are available before deciding on Rx?
Start IVI Acyclovir 10mg/kg 8 hourly immediately : 14 -21 days of Rx

                      Mortality reduced to 33% with early treatment

Question 12

Acute Liver Failure Hepatitis B

Answer 12

Jaundice x 1 week
Nausea and vomiting x 2 days
Found unresponsive in bed

Emergency Treatment

IVI 5% Dextrose Saline drip

IVI 20% Mannitol - 0,5-1g/kg – given as a stat dose and repeated 4-6 hourly – must have urine output

Assess need for intubation

Investigations
Na 128 K 5.4 Urea 12 Creatinine 259
TBil 325 CBil 278 ALT 4267 AST 5643 ALP 197 GGT 87
pH 7.29 Lactate 3.4
Hb 12,3 WCC 12 Platelets 97
INR 7,2
Hepatitis B sAg, hepatitis B IgM core Ab positive
HBV DNA 90 564 IU/ml
HIV negative

Acute Hepatitis B: ALF complicated by cerebral oedema and hepatorenal syndrome

Specific Treatment: Lamivudine

ALF can occur as result of

Fulminant presentation of acute hepatitis B

 More common if co-infection with HIV and HBV

Reactivation during chemotherapy or immunosuppression

HB IgM core Ab maybe only positive serological marker

Lamivudine 150 mg daily in the acute setting

Conversion to Tenofovir 300mg daily once clinically stable