CHAPTER 106: Acute Liver Failure

KEY POINTS

• Acute liver failure is a syndrome with sudden loss of liver function denoted by coagulopathy and encephalopathy in a patient without previous liver disease.

• Etiologies vary greatly, with viral hepatitis infections and acetaminophen toxicity among the most common.

• Shock, kidney failure, and encephalopathy are common complications of acute liver failure.

• Severe sepsis is a common complication of acute liver failure.

• Aggressive supportive care in a center that performs liver transplantation will optimize patient outcomes.

SUMMARY

The term acute liver failure is frequently used as a generic expression to describe a large and diffuse cohort of patients presenting with or developing an acute episode of liver dysfunction, usually manifested by deterioration in liver blood tests and other organ dysfunction.

This chapter largely addresses a cohort of patients with primary acute liver failure (ALF), that is patients with acute liver dysfunction manifested by transaminitis, coagulopathy, and encephalopathy in the setting of a previously normal liver. The etiology of these disturbances should be primarily liver in aetiology and as such, the coagulopathy and altered conscious level should be attributable to the liver failure as opposed to other etiologies such as systemic disease processes or sepsis. The later processes are typically described in the context of a secondary liver injury.

Management of patients with ALF should focus upon prevention and removal of any potentiating agents and support of the liver and other organs to facilitate regeneration and recovery. A small proportion of patients with ALF will have a liver injury that does not have the capacity to repair and regenerate and as such will need the option of emergent liver transplantation.

ALF: DESCRIPTION AND AETIOLOGY

ALF describes a syndrome incorporating sudden loss of liver function denoted by the features of coagulopathy and encephalopathy in a patient without previous liver disease. The disease process should result from primary liver insult, and the coagulopathy and altered conscious level should occur as a result of liver failure as opposed to a systemic process such as sepsis.^1,2

ALF was subdivided, by O’Grady and colleagues, into hyperacute, acute and subacute, while previous descriptions had utilized fulminant and subfulminant terminologies, with times lines of up to 8 weeks and 8 to 24 weeks, respectively.³ For practical reasons acute and hyperacute have been merged to describe management. Disease processes resulting in encephalopathy after 24 weeks are categorized as chronic liver disease and fall outside the scope of this chapter.

Similarities of disease process and complications are seen for hyperacute, acute, and fulminant groups; while the subacute and subfulminant groups have different presentations and characteristics.⁴

The acute type presentations demonstrate severe coagulopathy, transaminitis, and initially only moderate, if any, increases in bilirubin; by contrast, the subfulminant/subacute often present with minor transaminitis, deep jaundice, and mild to ...