Liver Failure Flashcards
Liver failure and “mushroom hunter” diagnosis and treatment
Amanita toxicity
tx with charcoal, Pen G, and Silibinin
Liver failure, pregnant, high transaminase levels and platelets abnormal
Acute fatty liver of pregnancy/HELLP syndrome
Tx is delivery
Liver failure and traveling to HBV endemic area
Hep B infection
Tx entecavir
Liver failure and immunocompromised, possible skin vesicles
HSV
Tx acyclovir
Liver failure in young patient with ulcerative colitis
Autoimmune hepatitis
Tx steroids
Liver failure, kayser fleischer rings
Wilson’s disease
Tx transplant (temporize with plasma exchange)
Liver failure and hypercoagulable
Budd Chiari
Tx with anticoagulation and possible TIPS
4 differentials for acute liver failure with transaminase levels > 10K
APAP toxicity
Shock liver
Viral infection
Mushroom ingestion
Drug given to all acute liver failure patient’s regardless of APAP ingestion
N-acetyl-cysteine
4 criteria for diagnosis of acute liver failure
No chronic liver disease
< 26 weeks in onset
INR > 1.5
Encephalopathy
Hyperacute liver failure time duration
0-1 week
Acute liver failure time duration
1-4 weeks
Subacute liver failure time duration
4-26 weeks
Staggered vs single dose tylenol ingestion, which has the worse outcome if toxic?
Staggered
4 drugs common for causing acute liver failure
INH
Bactrim
Nitrofurantoin
Azoles
Seizure drug known for causing acute liver failure
Phenytoin
3 common herbals/supplements known for causing acute liver failure
Hydroxycut (phentolamine)
KAVA
Mahuang
Preferred method of dialysis in patients with acute liver failure, particularly if ammonia > 200
CRRT > HD
Grade 0 hepatic encephalopathy symptoms
None, normal patient
Grade 1 hepatic encephalopathy symptoms
Mild confusion, short attention span
Grade 2 hepatic encephalopathy symptoms
Disoriented, personality changes, inappropriate behavior
Grade 3 hepatic encephalopathy symptoms
Stuporous but arousable
Grade 4 hepatic encephalopathy symptoms
Coma
Cause of mortality in patient’s with grade 3 and 4 hepatic encephalopathy
Cerebral edema
Chronic liver failure drugs that do not work in acute liver failure for hepatic encephalopathy
Lactulose, rifaximin, neomycin (no survival benefit)
Map Goal in hepatic encephalopathy for acute liver failure
MAP > 75
Osmolality requirement for the use of mannitol in hepatic encephalopathy from acute liver failure
< 320
Does therapeutic hypothermia work in acute liver failure for reduction of brain damage from cerebral edema?
No
Liver disease severity score for patients with acute vs chronic liver failure
Acute - kings college criteria
Chronic - MELD
5 reasons to refer for liver transplant evaluation
Coagulopathy (APAP INR > 3.0 or non-APAP > 1.8)
Acidosis (pH < 7.30, HCO3 < 18, Lactate elevated)
Hypoglycemia
Encephalopathy
Acute kidney injury
Typical transaminase profile in patients with acute liver failure due to alcoholic hepatitis
AST > 2x normal but rarely > 400
AST/ALT ratio > 2
Bilirubin > 3
Severe alcoholic hepatitis discriminant function threshold
> 32
Formula for discriminant function
4.6 x (patient - control PT) + bilirubin
When to stop steroids for alcoholic liver failure
After day 7 if no improvement
If they are improving, continue through day 28, then taper
Drug that can be used in place of prednisone in alcoholic liver failure
Pentoxifylline
Drug class that does not work in alcoholic liver disease
TNF agents
2 criteria for SBP diagonsis
Absolute neutrophil count > 250
No organisms on gram stain (if there are, think bowel perf)
Treatment for SBP
3rd gen cephalosporin
FQ if PCN allergic
Tx for 5 days
Albumin 1.5 g/kg on day 0, then 1 gm/kg on day 3 (reduces mortality and renal failure)
2 things not to do or stop in patients with SBP
Stop non-selective beta blockers
Avoid large volume paracentesis (> 5L)
2 medicines to give in hepatic encephalopathy in chronic liver failure
Lactulose and rifaximin
Does treating hyponatremia > 120 and no neurologic symptoms help outcomes in chronic liver failure
No
Treatment for hyponatremia in chronic liver failure
Free water restriction usually
Hypertonic saline if neurologic symptoms
DON’T give salt tablets or vasopressin medications (mortality increase)
Amount of albumin to give in patients after doing paracentesis
After 5L removed, give 5g/L removed
Criteria for hepatorenal syndrome in someone with liver failrue
Cr > 1.5 AND
Unchanged after albumin 1g/kg and 2 days off diuretics AND
Absence of nephrotoxic drugs, shock, abnormal urine, or abnormal renal US
Difference between type 1 and type 2 hepatorenal syndrome
Type 1 -
Cr doubles over = 2 weeks OR 50% reduced Cr Clearance
Type 2 -
Stable, slower progression than type 1 (months)
Map goal in treating hepatorenal syndrome
Map increase 10-15 mmHg
