Liver failure

Question 1

Acute liver failure

Answer 1

• Acute onset of: jaundice, encephalopathy, coagulopathy
• No known pre-existing liver disease
• Fulminant is very acute (w/in 2 wks) and very severe
• Hyperacute is <7 days
• Most common cause: acetaminophen OD
• Other causes: HAV, HBV, HBV+HDV, HEV, idiosyncratic (usually antibios), hypersensitivity, autoimmune, metabolic disease, acute fatty liver of pregnancy, ischemic, indeterminate (2nd most common cause

Question 2

Outcomes of ALF

Answer 2

• Depends on etiology, severity, complications, etc
• Using n-acetylcysteine for acetaminophen OD has helped greatly
• In some cases of acetaminophen OD the only thing that will help is liver Tx (king’s college criteria)
• KCC (for acetaminophen): pH6 and Cr >3.3 and grade 3 or 4 (arousable only, coma) encephalopathy
• KCC (not acetaminophen related): INR >6 or age 40 w/ hep C or drug reaction and encephalopathy + jaundice and INR >3.5 and bill >17
• If ALF not due to acetaminophen, then supportive care is only option

Question 3

Complications of ALF 1

Answer 3

• Encephalopathy and cerebral edema
• Edema compromises blood flow and can lead to tonsils herniation thru foramen magnum
• Want to hyperventilate pt to induce hypocapnia and cerebral vasoconstriction, can use mannitol
• Coagulopathy and hemorrhage
• Can lead to DIC, thrombocytopenia
• Important to only administer FFP if pt is actively bleeding (otherwise FFP will normalize the PT/INR, which is most sensitive test for recovery)

Question 4

Complications of ALF 2

Answer 4

• Metabolic derangements and hypoglycemia
• Infections (usually bacterial, broad spectrum antibios)
• Multi-system organ failure: pulm failure (intubate at stage 3/4 encephalopathy), renal failure, CV collapse (hypotension and arrhythmias)
• Renal failure: can be ATN from acetaminophen or hepatorenal syndrome due to cytokine release from liver -> RA constriction and decreased blood flow ischemia

Question 5

Chronic liver failure

Answer 5

• Seen in advanced cirrhosis: fibrous tissue and regenerative nodules, bilirubin excretion and protein synthesis impairment, alteration in hepatic blood flow
• Etiologies: alcohol, chronic viral hepatitis, autoimmune hepatitis, cholestatic liver disease (primary/secondary biliary cirrhosis, primary sclerosing cholangitis), inherited metabolic d/os (wilson’s, hemochromatosis, A1AT), non-alcoholic steatohepatitis (NASH), others

Question 6

Complications of cirrhosis

Answer 6

• Encephalopathy
• Ascites
• Esophageal/gastric varices
• Splenomagaly (thrombocytopenia)
• Hepatorenal syndrome (HRS)
• Hepatopulmonary syndrome (HPS)
• Porto-pulmonary HTN (PPHTN)
• Impaired excretion of bile-> hyperbilirubinemia
• Impaired synthetic function: hypoalbuminemia, prolonged INR

Question 7

Child-turcotte-pugh (CTP) score)

Answer 7

• A, B, C, w/ increasing severity of cirrhosis
• Based on encephalopathy, ascites, bill, albumin, INR
• A has 10 yr 50% survival, C has 2 yr 50% survival
• MELD score determines position on Tx list

Question 8

Endpoints of CLF

Answer 8

• Decompensated cirrhosis (symptomatic)
• HCC
• Liver Tx
• Death