Uploaded byHoangPhung15
151 views

Acute liver failure

Acute liver failure is defined as severe liver injury with coagulopathy and encephalopathy occurring within 26 weeks in a patient without preexisting cirrhosis. The most common etiologies are drug-induced liver injury and viral hepatitis. A thorough history, physical exam, and lab workup is needed to determine the underlying cause and prognosis. Complications can include multi-organ failure, bleeding, infection, and cerebral edema. Treatment involves supportive care, identifying and treating any underlying etiology, and consideration of liver transplantation in severe cases.

Education◦
In this document
Powered by AI

Introduction to Acute Liver Failure, overview by Phung Huy Hoang, Resident in Internal Medicine.

Definition includes coagulopathy, mental alteration, cerebral edema, and disease duration. Types include hyperacute, acute, subacute.

Causes include drugs, toxins, viruses, autoimmune, metabolic, and indeterminate factors. Key etiologies and mechanisms discussed.

Major complications include multi-organ failure, infection, hemorrhage, and cerebral edema with emphasis on implications.

Factors indicating prognosis include etiology, King’s College Criteria, and other scoring systems to assess patient status.Management includes supportive care, transplantation, and liver support devices. Discusses qualification for liver transplant.

Infections are significant causes of death in acute liver failure. Management includes surveillance and antibiotics.Cardiovascular dysfunction management in ALF includes fluid resuscitation, blood pressure support, and monitoring.

Discussion on renal failure pathophysiology in ALF and management strategies including fluid resuscitation.

Prevention strategies include antiviral therapies and education on overdose prevention. Importance of psychiatric support.

List of references providing background and guidelines for acute liver failure treatment and management.

Embed presentation

Download to read offline
ACUTE LIVER FAILURE PHUNG HUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
OVERVIEW APPROACH PROGNOSIS MANAGEMENT COMPLICATIONS PREVENTION
OVERVIEW ACUTE LIVER FAILURE PHUNG HUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
DEFINITION • Coagulation abnormality (usually INR > 1.5) • Any degree of mental alteration (encephalopathy) • Virtually unique clinical feature: cerebral edema • Without preexisting cirrhosis • Illness of < 26 weeks’ duration • Exceptions: Wilson disease, vertically acquired HBV, autoimmune hepatitis, Budd- Chiari syndrome, HDV superinfection in patients with chronic HBV infection (present with ALF despite presence of unrecognized underlying chronic liver disease or cirrhosis) • Wendon J., Panel m., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081 • William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update“ • Larson A. M. (2012), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley-Blackwell, pp. 445-472
CLASSIFICATION NOT particularly helpful since they do not have prognostic significance distinct from the cause of the illness • William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update“ • Willars C., Wendon J. (2014), Oh’s Intensive Care Manual, Andrew D Bersten , Neil Soni, Editors, Elsevier, pp. 501-519 7 days 21-28 days 26 weeks Hyperacute Acute Subacute Acetaminophen overdose, hepatitis A, and B,… Hepatitis ABE, idiosyncratic drug reactions,… Idiosyncratic drug reaction, seronegative hepatitis,… Interval from onset of disease (usually jaundice) to onset of encephalopathy
Wendon J., Panel m., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
Kuntz E., Kuntz H.-D. (2008), Hepatology Textbook And Atlas, Springer, pp. 380-396
Wendon J. (2015), Principles of Critical Care, Gregory A. Schmidt Jesse B. Hall, John P. Kress, Editor, McGraw Hill Education, pp. 1022-1026
ETIOLOGY • Different etiologies typically have a specifc time frame • Etiological diagnosis: strongest determinant of outcome1,2 1. William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update“ 2. Ziv Y. H., Collins M. H., Rothenberg M. E. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 1973-1988 3. Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
ETIOLOGY Drugs and toxins Viruses (Hepatotropic, Nonhepatotropic) Autoimmune diseases Metabolic diseases Vascular causes Infiltrative diseases Indeterminate (up to 10-15%*) (*) Spengler E., Fontana R. J. (2018), Handbook of Liver Disease, Lawrence S. Friedman , Paul Martin, Editors, Elsevier Saunders, pp. 18-33
INFECTION • Hepatitis A, B (±D), E • Hemorrhagic fever viruses, CMV, HSV, EBV, adenovirus, VZV, Parvovirus B19 • Leptospira, listeria, malaria. M. tuberculosis, rickettsia, syphilis DRUGS/TOXINS • Dose-related: Acetaminophen, Carbon tetrachloride, Amanita poisoning, Bacillus cereus emetic toxin, Cyanobacteria microcystins, sulfonamide, tetracycline • Idiosyncratic: Reye’s syndrome (salicylic acid), Herbal medications, Prescription medications (i.e., isoniazid, halothane, troglitazone, bromfenac, valproic acid) VASCULAR • Budd–Chiari syndrome, Sinusoidal obstruction syndrome Ischemic (shock) liver METABOLIC/GENETIC • Galactosemia • Fructose intolerance • Tyrosinemia • Neonatal iron storage disease • Wilson disease • α1-Antitrypsin deficiency NEOPLASTIC • Metastases: breast, melanoma, lung, lymphoma PREGNANCY-RELATED • Acute fatty liver of pregnancy • HELLP syndrome MISCELLANEOUS • Autoimmune hepatitis • Heat stroke • Primary graft nonfunction in liver transplant recipients INDETERMINATE
Ziv Y. H., Collins M. H., Rothenberg M. E. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 1973-1988
O’Grady J. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1591-1602
Larson A. M. (2012), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley-Blackwell, pp. 445-472
Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
• William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update“ • Larson A. M. (2012), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley-Blackwell, pp. 445-472 Drug classes associated with acute liver failure: Halothane, antituberculosis, anticonvulsants, antibiotics, antineoplastic, antiretroviral, MDMA (ectasy), NSAIDs
O’Grady J. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1591- 1602
Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
Murphy N. (2013), Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334.
PATHOPHYSIOLOGY • Characteristics: • Massive hepatocyte necrosis • OR without histologic evidence of hepatocellular necrosis (acute fatty liver of pregnancy and Reye’s syndrome) • Abrupt loss in hepatic metabolic and immunologic functions  encephalopathy, coagulopathy, infection, multi-organ failure
Ziv Y. H., Collins M. H., Rothenberg M. E. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 1973- 1988
Fontana R. J., Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
Fontana R. J., Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
COMPLICATIONS Multiorgan failure (renal, circulatory, respiratory,… ) Hemorrhage Infection HE/Cerebral edema Hypoglycae mia Acid-base disorders
Wendon J., Panel m., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
APPROACH ACUTE LIVER FAILURE PHUNG HUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
ALF DIAGNOSIS ESTABLISHED • Clinical or laboratory evidence of acute hepatitis • PT prolonged ≥ 4-6 seconds (INR ≥ 1.5) • Any evidence of altered sensorium ALF may be mistaken for cirrhosis and opportunity to be considered for transplantation losts
Wendon J., Panel m., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
HISTORY AND PHYSICAL EXAMINATION • Review of possible exposures to viral infection and drugs (prescribed and OTC) or other toxins • History of abnormal LFTs • Mental status examination • Stigmata of chronic liver disease (palmar erythema, spider angiomata, caput medusae, gynecomastia, testicular atrophy, ascites/portal hypertension,…) • Jaundice • Right upper quadrant tenderness • Palpate and percuss area of liver • Enlarged = viral hepatitis, malignant infiltration, congestive heart failure, acute Budd-Chiari syndrome • Loss of liver volume due to massive hepatocyte loss
LABORATORY EXAMINATION William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update"
LABORATORY EXAMINATION • Complete blood count: • Leukocytosis: can be seen with acute hepatitis from any etiology (high risk for infection) • Thrombocytopenia: DIC, acute on chronic process. • Hemolytic anemia with Coombs (-): classically in fulminant Wilson disease. • Blood type and screen: two drawn independently needed for transplant evaluation, may require blood products as part of supportive care. • Acidosis,  arterial lactate = poor prognostic marker. • Arterial ammonia: >200µg/dL = strongly associated with cerebral herniation. • Toxicology screen (serum, urine): etiology of ALF and determine appropriateness of transplant candidacy (active drug abusers: not candidates for transplant) • Acetaminophen level
LABORATORY EXAMINATION • Viral serologies: anti-HAV IgM, HBsAg, anti-HBc IgM, anti-HEV, anti-HCV, HSV-1 and HSV-2 IgM, VZV, CMV IgM • Ceruloplasmin: low or normal consistent with Wilson disease. Levels may be normal since it is an acute phase reactant. • Uric acid: if Wilson disease is suspected, levels may be low. • Autoimmune markers: ANA, ASMA, IgG levels. • Pregnancy test in females. • HIV status (HIV-1, HIV-2) • Amylase and lipase.
LABORATORY EXAMINATION • Imaging techniques • Liver US with Doppler • Abdominal CT scan with contrast or MRI with gadolinium (malignant infltration, Budd–Chiari syndrome, portal vein thrombosis) • Non-contrast head CT: rule out other causes of changes in mental status (not helpful to identify cerebral edema)
Fontana R. J., Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
Murphy N. (2013), Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334.
LIVER BIOPSY • Indications: limited • History of cancer or significant hepatomegaly: malignant infiltration should be excluded by imaging or liver biopsy • Performed preferably by a transjugular route, in a centre experienced in its use, and with access to a histopathologist with liver experience Wendon J., Panel m., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
Wendon J., Panel m., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
PROGNOSIS ACUTE LIVER FAILURE PHUNG HUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
UNOS (United Network for Organ Sharing) Criteria for Status I Listing King’s College Criteria (KCH) MELD score (Model for End-stage Liver Disease) ALFSG (Acute Liver Failure Study Group Model) French Clichy Criteria APACHE II (Acute Physiology and Chronic Health Evaluation) scoring system
Aditi A., Crippin J. S. (2012), The Washington Manual of Critical Care, Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 376-386
Wendon J., Panel m., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
Fontana R. J., Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
Wendon J., Panel m., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
Murphy N. (2013), Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334.
OTHER INDICATORS OF POOR PROGNOSIS • Etiology • Idiosyncratic drug injury • Acute hepatitis B (and other non-hepatitis A viral infections) • Autoimmune hepatitis • Mushroom poisoning • Wilson disease • Budd-Chiari syndrome • Indeterminate cause • Coma Grade on Admission: III or IV
MANAGEMENT ACUTE LIVER FAILURE PHUNG HUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
PRINCIPLES • Supportive care • Nutrition: Patients with ALF  resting energy expenditure  enteral or parenteral nutrition warranted • Venous thrombosis prophylaxis • Specific therapies • Treatment of complications • Liver transplantation: should be considered in all patients (King’s College criteria, modified King’s College criteria)
Fontana R. J., Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
LIVER TRANSPLANTATION • Urgent hepatic transplantation: prognostic indicators suggest a high likelihood of death • Living donor or auxiliary liver transplantation: considered in the setting of limited organ supply (remains controversial) • King’s College Criteria or French Clichy Criteria • CONTRAINDICATIONS: • Severe cardiopulmonary disease or multiorgan failure • Septic shock • Extrahepatic malignant disease • Extensive thrombotic disease • Irreversible brain injury or brain death: CPP < 40 mmHg for >2 hours; Sustained ICP > 50 mmHg • Active substance abuse, repeated suicide attempts, or inadequate social support may preclude transplant candidacy
Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update"
Fontana R. J., Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
LIVER SUPPORT SYSTEM • ARTIFICIAL SUPPORT = adsorben (plasmapheresis, molecular absorbents recirculation system-MARS) • BIOARTIFICIAL SUPPORT (HepatAssistTM (Arbios, formerly Circe, Waltham MA), extracorporeal liver support device (ELADTM; Vital Therapies, San Diego, CA), modular extracorporeal liver support system (MELSTM; Charité, Berlin, Germany), bioartificial liver support system (BLSSTM; Excorp Medical, Minneapolis MN), and the Amsterdam Medical Center bioartificial liver (AMCBALTM; AMC, Amsterdam, The Netherlands) Currently available liver support systems are not recommended outside of clinical trials; their future in the management of acute liver failure remains unclear William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update"
Larson A. M. (2012), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley-Blackwell, pp. 445-472
Larson A. M. (2012), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley-Blackwell, pp. 445-472
Fontana R. J., Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
COMPLICATIONS ACUTE LIVER FAILURE PHUNG HUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
HEPATIC ENCEPHALOPATHY/CEREBRAL EDEMA • Hepatic encephalopathy occurs in the presence or absence of cerebral edema • Cerebral edema and intracranial hypertension: most serious complications of ALF (> 20% of death)  uncal herniation, death (differentiated from that of cirrhosis) • Cerebral edema  ischemic + hypoxic brain injury  long-term neurological deficits in survivors • Risk of cerebral edema increases with the severity of encephalopathy •  arterial NH3 > 200 μmol/L = increased risk of developing ICH • Infections, hyperthermia:  risk of HE • Pathogenic mechanisms: not entirely understood (osmotic disturbances,  cerebral blood flow due to loss of cerebrovascular autoregulation, inflammation and/or infection) • Clinical signs: often unreliable and occur very late • Head CT: should be considered in grades 3 or 4 HE  cerebral edema or intracranial bleeding
HIGH RISK FOR CEREBRAL EDEMA • < 40 years of age • Very low or high JV O2 sat • Serum NH3 > 150 M • Severe hyponatremia <130 mmol/L • Grade 3/4 HE • Acute renal failure • Requiring vasopressors to maintain MAP • William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update“ • Murphy N. (2013), Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334. HEPATIC ENCEPHALOPATHY/CEREBRAL EDEMA
Willars C., Wendon J. (2014), Oh’s Intensive Care Manual, Andrew D Bersten , Neil Soni, Editors, Elsevier, pp. 501-519
Murphy N. (2013), Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334.
Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301- 323
Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
Fontana R. J., Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
Willars C., Wendon J. (2014), Oh’s Intensive Care Manual, Andrew D Bersten , Neil Soni, Editors, Elsevier, pp. 501-519 CCP = MAP - ICP
Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
Ziv Y. H., Collins M. H., Rothenberg M. E. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 1973-1988
MANAGEMENT (1) • Consider admitted to ICU ± transfer to transplant center • Head of bed at 30 degrees, correct factors  ICP (quiet room with minimal suctioning/noxious stimuli, intratracheal lidocaine before respiratory suctioning, treat agitation, monitor for and treat seizures, correct hypoxemia, volume overload, hypotension) • Intracranial pressure monitoring; Neurological checks q4h • Avoid narcotics and sedatives (if patient agitated  more important to keep patient calm) • Seizures ( ICP, cerebral hypoxia  cerebral edema): • Phenytoin: treatment (loading 20 mg/kg with dose adjusted in the setting of renal failure followed by maintenance dosing) • Prophylactic phenytoin: NOT recommended • Short-acting BZD: phenytoin-refractory cases HEPATIC ENCEPHALOPATHY/CEREBRAL EDEMA
Fontana R. J., Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
O’Grady J. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1591-1602
Murphy N. (2013), Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334.
MANAGEMENT (2) • Mannitol (0.5g/kg IV; repeated 1–2 times as needed if serum osmolality < 320 mosm/L): contraindicated in renal failure • Prophylactic induction of hypernatremia = hypertonic saline (to a sodium level of 145-155 mEq/L): recommended for highest risk of cerebral edema • Lactulose: ± • Early stages of encephalopathy (orally or rectally) to effect a bowel purge (should not be administered to the point of diarrhea) • May lead to colonic distension = unfavorable in transplant setting) • Endotracheal intubation: high-grade HE (grade III or IV) • Corticosteroids: should NOT be used to control elevated ICP in patients with ALF • Hyperventilation: NO role HEPATIC ENCEPHALOPATHY/CEREBRAL EDEMA
William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update"
Gonzalez S. A., Keeffe E. B. (2012), Handbook of Liver Disease, Lawrence S. Friedman , Emmet B. Keeffe, Editors, Elsevier Saunders, pp. 20-33
Aditi A., Crippin J. S. (2012), The Washington Manual of Critical Care, Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 376-386
COAGULOPATHY • Mechanism: • Loss of hepatocellular function   synthesis of coagulation (Factor II, V, VII, IX, and X) and fibrinolysis factors and inhibitors +  breakdown of activated factors • Abnormalities in platelet count ( thrombopoietin), function, and morphology • Consumption of clotting factors and platelets • GI bleeding: from superfcial gastric erosions and stress ulcers • Key feature of ALF + important prognostic indicator • Risk of severe hemorrhage: 10%1,2 (gastrointestinal tract, nasopharynx, lungs, puncture sites, and retroperitoneum) 1. Spengler E., Fontana R. J. (2018), Handbook of Liver Disease, Lawrence S. Friedman , Paul Martin, Editors, Elsevier Saunders, pp. 18-33 2. Hay J. E. (2010), Practical Gastroenterology and Hepatology - Liver and Biliary Disease, Nicholas J. Talley, Keith D. Lindor, Hugo E. Vargas, Editors, Blackwell Publishing, pp. 113-123.
COAGULOPATHY MANAGEMENT • Expectant (thrombogenic and thrombolytic pathways that may balance each other!) • Vitamin K 10 mg (IV or SC): 3 days for all patients • Platelet transfusions, FFP, cryoprecipitate: • Active bleeding • Need for invasive procedures (liver biopsy, placement of an intracranial monitoring device, CVC,…) Goal: PLT > 50.000/mm3, INR < 1.5, Fibrinogen > 100 mg/dL • Recombinant factor VII: may be used with caution and only under certain conditions • Prophylactic acid suppression = H2RA or PPIs (1st line), sucralfate (2nd line): ICU patient • Plasma exchange may also be used to correct coagulopathy (*) William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update"
Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323 Model of rebalanced hemostasis in acute liver failure
Fontana R. J., Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
INFECTION • One of the major causes of death • 80% of patients with FHF* • Mechanism: • Kupffer cell malfunction   clearance of gut-derived bacteria + endotoxin • Impaired uptake   fibronectin (important co-factor made by the liver needed for opsonization) • Neutrophil malfunction (phagocytosis, opsonization, mobility): may be related to  serum complement levels • Defective lymphocyte function  cell-immunity • NOT ONLY from gut-derived organisms but also from Gram-positive organisms (*) Aditi A., Crippin J. S. (2012), The Washington Manual of Critical Care, Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 376-386
Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
INFECTION • Periodic surveillance cultures (detect bacterial and fungal pathogens as early as possible) • Antibiotic treatment: • Low threshold for initiation of broad-spectrum coverage should be maintained = surveillance culture results or at earliest sign of active infection or deterioration (progression to high grade HE or elements of the SIRS) • Empiric: 3rd generation cephalosporin/FQ + vancomycin • Systemic antifungal therapy (amphotericin, fluconazole, or caspofungin): prolonged antibiotics, MICU stay, renal failure, emergent transplantation • Prophylactic antibiotics and antifungals: NOT been shown to improve overall outcomes in ALF • Granulocyte colony-stimulating factor (GCSF): ±
CARDIOVASCULAR DYSFUNCTION • Low systemic and pulmonary vascular resistance • Compensatory increase in cardiac output • Increased metabolic rate • Abnormal oxygen transport and uptake • Impaired responses to adrenocorticotropic hormone (ACTH) # septic shock pathologic state
Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
CARDIOVASCULAR DYSFUNCTION MANAGEMENT • Supplemental oxygen. • Hemodynamic monitoring of central pressures • Blood transfusions if needed ( oxygen carrying capacity) • Fluid resuscitation and maintenance of adequate intravascular volume • Blood pressure support: • Systemic vasopressor support (norepinephrine or dopamine)  maintain MAP ≥ 75mmHg1. • Dobutamine: considered if severe LV dysfunction (may worsen hypotension) • Vasopressin: should be AVOIDED (effects on  cerebral blood flow and intracranial hypertension) • Hydrocortisone trial (200-300 mg/day): persistent hypotension despite fluid resusciation and vassopressor (not reduce mortality but does  vasopressor requirements2) 1. William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update“ 2. Wendon J., Panel m., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
RENAL FAILURE • Pathophysiology • Direct nephrotoxicity (eg, Acetaminophen, etc.) • Hepatorenal syndrome (intense renal vasoconstriction  systemic vasodilation) • Hypovolemia • Impaired hepatic urea production  underestimation of renal impairment • Key early prognostic indicator • MANAGEMENT: • Fluid resuscitation and maintenance of adequate intravascular volume • Avoidance of nephrotoxic agents • Dialysis support when needed: continuous mode (CVVH – avoid heparin if possible) rather than an intermittent mode (limit fluctuations in systemic pressure and cerebral perfusion pressure)
Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
METABOLIC DERANGEMENT • Hypoglycemia: defective gluconeogenesis +  hepatic glycogen production + inadequate hepatic uptake of insulin • Hypophosphatemia: ATP consumption/rapid hepatocyte regeneration +  urinary loss • Acidosis (important predictor of mortality) and alkalosis (hyperventilation) • Electrolyte and metabolic derangements: contribute to progressive HE +  risk of cerebral edema
PREVENTION ACUTE LIVER FAILURE PHUNG HUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
• Before onset of chemotherapy or immunosuppressive therapy + HBsAg (+) • Prophylactic oral nucleoside or nucleotide antiviral therapy (several weeks before) • Antiviral maintenance: • HBV-DNA < 2000 UI/mL: 6 months after completion of chemotherapy or immunosuppressive therapy • HBV-DNA > 2000 UI/mL: until HBV DNA undetectable + ALT levels normalized • Limiting availability of bulk acetaminophen • Psychiatric assistance: depression and have attempted suicide • Patient education: accidental overdose (*) Bansal M. B. (2014), Mount Sinai Expert Guides - Hepatology, Jawad Ahmad, Scott L. Friedman, Henryk Dancygier, Editors, Wiley Blackwell, pp. 280-293.
O’Grady J. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1591-1602
O’Grady J. (2016), Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1591-1602
REFERENCES ACUTE LIVER FAILURE PHUNG HUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
1. Fontana R. J., Bari K. (2018), "Acute Liver Failure", Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431. 2. Larson A. M. (2012), "Acute Liver Failure", Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley-Blackwell, pp. 445-472. 3. Aditi A., Crippin J. S. (2012), "Fulminant Hepatic Failure", The Washington Manual of Critical Care, Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 376-386. 4. Bansal M. B. (2014), "Acute Liver Failure", Mount Sinai Expert Guides - Hepatology, Jawad Ahmad, Scott L. Friedman, Henryk Dancygier, Editors, Wiley Blackwell, pp. 280-293. 5. Hay J. E. (2010), "Acute Liver Failure", Practical Gastroenterology and Hepatology - Liver and Biliary Disease, Nicholas J. Talley, Keith D. Lindor, Hugo E. Vargas, Editors, Blackwell Publishing, pp. 113-123. 6. Karvellas C. J., Stravitz R. T. (2018), "Acute Liver Failure", Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323. 7. Kuntz E., Kuntz H.-D. (2008), "Acute and chronic liver insufficiency", Hepatology Textbook And Atlas, Springer, pp. 380-396. 8. Murphy N. (2013), "Diagnosis and Management of Liver Failure in the Adult", Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334. 9. O’Grady J. (2016), "Acute Liver Failure", Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1591-1602. 10. Spengler E., Fontana R. J. (2018), "Acute liver failure", Handbook of Liver Disease, Lawrence S. Friedman , Paul Martin, Editors, Elsevier Saunders, pp. 18-33. 11. Wendon J. (2015), "Acute Liver Failure", Principles of Critical Care, Gregory A. Schmidt Jesse B. Hall, John P. Kress, Editor, McGraw Hill Education, pp. 1022-1026.
12. Wendon J., Panel m., Cordoba J., et al. (2017), "EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure", J Hepatol, 66 (5), pp. 1047-1081. 13. Willars C., Wendon J. (2014), "Liver failure", Oh’s Intensive Care Manual, Andrew D Bersten , Neil Soni, Editors, Elsevier, pp. 501-519. 14. William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update". 15. Ziv Y. H., Collins M. H., Rothenberg M. E. (2016), "Acute liver failure", Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 1973-1988.
ACUTE LIVER FAILURE PHUNG HUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018

More Related Content

PPTX
Acute Liver Failure
byDee Evardone
 
PPTX
Acute liver failure
bySuresh Gorka
 
PPTX
SBP and hepatic encephalopathy
byKimberly Treier
 
PPTX
TIA and stroke prevention
byLobna A.Mohamed
 
PPTX
Approach to a patient in shock
byAnkur Kaushik
 
PPT
peripherial arterial disease
byNote Noteenote
 
PPTX
"Paraquat Poisoning: Clinical Insights, Management, and Challenges" - by Dr B...
byDr Bodhisatwa Choudhuri
 
PPTX
ATRIAL FIBRILLATION
byBest Doctors
 
Acute Liver Failure
byDee Evardone
 
Acute liver failure
bySuresh Gorka
 
SBP and hepatic encephalopathy
byKimberly Treier
 
TIA and stroke prevention
byLobna A.Mohamed
 
Approach to a patient in shock
byAnkur Kaushik
 
peripherial arterial disease
byNote Noteenote
 
"Paraquat Poisoning: Clinical Insights, Management, and Challenges" - by Dr B...
byDr Bodhisatwa Choudhuri
 
ATRIAL FIBRILLATION
byBest Doctors
 

What's hot

PPTX
Acute liver failure
bySuresh Gorka
 
PPTX
HTN EMERGENCIES AND URGENCIES
byPraveen Nagula
 
PPTX
Primary Sclerosing Cholangitis (PSC)
byKailash Raj
 
PDF
toaz.info-patient-centered-family-focused-community-oriented-care-matrix-pr_8...
byJayEsdrelon
 
PPTX
Heart Failure Approach class.pptx
byBest Doctors
 
PPTX
Acute liver failure.pptx
byCutiePie71
 
PPT
Acute liver failure
bySaqib Pervez
 
PPTX
Fulminant hepatic failure (fhf)
byReyad Al_Faky
 
PPTX
Epilepsy Syndromes
bydahmed hamed
 
PPTX
Acute liver failure
bymauryaramgopal
 
PPTX
Hepatic encephalopathy
byChandan N
 
PPTX
Hepatic Encephalopathy
byBhargav Kiran
 
PPTX
Approach to Shock (for Undergraduates)
byAbdullah Ansari
 
PPT
Approach to a patient with stroke
byAshwin Haridas
 
PPTX
Dizziness
byNeurologyKota
 
PPTX
Tb Pericarditis
byzhenya krapivinsky
 
PPTX
Rat poisoning management
byDhiraj Kumar Golla
 
PPT
Atrial Fibrillation by Dr. Aryan
byDr. Aryan (Anish Dhakal)
 
PPTX
Approach to quadriparesis
byDeepak Sharma
 
PPTX
Approach to seizure disorder
byz2jeetendra
 
Acute liver failure
bySuresh Gorka
 
HTN EMERGENCIES AND URGENCIES
byPraveen Nagula
 
Primary Sclerosing Cholangitis (PSC)
byKailash Raj
 
toaz.info-patient-centered-family-focused-community-oriented-care-matrix-pr_8...
byJayEsdrelon
 
Heart Failure Approach class.pptx
byBest Doctors
 
Acute liver failure.pptx
byCutiePie71
 
Acute liver failure
bySaqib Pervez
 
Fulminant hepatic failure (fhf)
byReyad Al_Faky
 
Epilepsy Syndromes
bydahmed hamed
 
Acute liver failure
bymauryaramgopal
 
Hepatic encephalopathy
byChandan N
 
Hepatic Encephalopathy
byBhargav Kiran
 
Approach to Shock (for Undergraduates)
byAbdullah Ansari
 
Approach to a patient with stroke
byAshwin Haridas
 
Dizziness
byNeurologyKota
 
Tb Pericarditis
byzhenya krapivinsky
 
Rat poisoning management
byDhiraj Kumar Golla
 
Atrial Fibrillation by Dr. Aryan
byDr. Aryan (Anish Dhakal)
 
Approach to quadriparesis
byDeepak Sharma
 
Approach to seizure disorder
byz2jeetendra
 

Similar to Acute liver failure

PPTX
Acute Liver Failure
byAnandNaik65
 
PDF
liver failure ppt.pdf
byDR NTR UNIVERSITY OF HEALTH SCIENCES,VIJAYAWADA,ANDHRA PRADESH,INDIA
 
PPTX
Acute & chronic liver failure
byFelisters Bosibori
 
PPTX
Acute liver failure
bygagan brar
 
PPTX
Management of fulminant hepatic failure final
byArif Mohd
 
PPT
Acute Liver Failure
byAmlendra Yadav
 
PPTX
Acute liver failure
byAshikMajumder1
 
PPTX
Fulminant hepatic failure.pptx
bycamiCatherine1
 
PPTX
Management of liver failure in general intensive care
byDr fakhir Raza
 
PPTX
Management of acute liver failure in critical care
byChamika Huruggamuwa
 
PPTX
acute liver failure
byChinna S
 
PPTX
An overview of acute liver failure 1,presentation 1.pptx
bybillionairebasilthes
 
PPTX
Recent Updates on Acute Liver failure.pptx
byBethelAberaHaydamo
 
PPTX
ACUTE LIVER FAILURE BY Dr Xaneera Qureshi.pptx
bydrxaneeraqureshi
 
PPTX
Overview of acute liver failure in emergency department.pptx
byalhayagem
 
PPTX
A seminar on Acute liver failure.pptx
bythomas616379
 
PDF
Acs0809 Hepatic Failure
bymedbookonline
 
PPTX
Acute liver failure resumen de guias.pptx
byBlaaaaaaaaaaaaa Apellidos
 
PPTX
acuteliverfailure, management-unedited.pptx
byUmarAliyuSaadu
 
PDF
managementofacuteliverfailureincriticalcare-160925104153.pdf
byHARYANVITRAVLLER
 
Acute Liver Failure
byAnandNaik65
 
liver failure ppt.pdf
byDR NTR UNIVERSITY OF HEALTH SCIENCES,VIJAYAWADA,ANDHRA PRADESH,INDIA
 
Acute & chronic liver failure
byFelisters Bosibori
 
Acute liver failure
bygagan brar
 
Management of fulminant hepatic failure final
byArif Mohd
 
Acute Liver Failure
byAmlendra Yadav
 
Acute liver failure
byAshikMajumder1
 
Fulminant hepatic failure.pptx
bycamiCatherine1
 
Management of liver failure in general intensive care
byDr fakhir Raza
 
Management of acute liver failure in critical care
byChamika Huruggamuwa
 
acute liver failure
byChinna S
 
An overview of acute liver failure 1,presentation 1.pptx
bybillionairebasilthes
 
Recent Updates on Acute Liver failure.pptx
byBethelAberaHaydamo
 
ACUTE LIVER FAILURE BY Dr Xaneera Qureshi.pptx
bydrxaneeraqureshi
 
Overview of acute liver failure in emergency department.pptx
byalhayagem
 
A seminar on Acute liver failure.pptx
bythomas616379
 
Acs0809 Hepatic Failure
bymedbookonline
 
Acute liver failure resumen de guias.pptx
byBlaaaaaaaaaaaaa Apellidos
 
acuteliverfailure, management-unedited.pptx
byUmarAliyuSaadu
 
managementofacuteliverfailureincriticalcare-160925104153.pdf
byHARYANVITRAVLLER
 

More from HoangPhung15

PDF
Acute metabolic complications of diabetes
byHoangPhung15
 
PDF
Bệnh thận do chất tương phản
byHoangPhung15
 
PDF
Clostridium difficile
byHoangPhung15
 
PDF
Contrast induced nephropathy
byHoangPhung15
 
PDF
Anaphylaxis
byHoangPhung15
 
PDF
Ascites
byHoangPhung15
 
PDF
Báng bụng
byHoangPhung15
 
PDF
Acute pancreatitis
byHoangPhung15
 
PDF
Diarrhea
byHoangPhung15
 
PDF
Blood transfusion complication
byHoangPhung15
 
PDF
Tilt table test - Nghiệm pháp bàn nghiêng
byHoangPhung15
 
PDF
Bệnh động mạch chủ
byHoangPhung15
 
PDF
Abdominal paracentesis - Chọc dò màng bụng
byHoangPhung15
 
PDF
Khí máu động mạch
byHoangPhung15
 
PDF
Tiếp cận ban đầu rối loạn nhịp tim nhanh
byHoangPhung15
 
PDF
ATRIOVENTRICULAR DISSOCIATION - Phân li nhĩ thất
byHoangPhung15
 
PDF
XỬ TRÍ TÌNH TRẠNG PHẢN VỆ TẠI KHOA LÂM SÀNG
byHoangPhung15
 
PDF
TIẾP CẬN THĂM KHÁM VÀ CHẨN ĐOÁN BỆNH LÍ LÁCH
byHoangPhung15
 
Acute metabolic complications of diabetes
byHoangPhung15
 
Bệnh thận do chất tương phản
byHoangPhung15
 
Clostridium difficile
byHoangPhung15
 
Contrast induced nephropathy
byHoangPhung15
 
Anaphylaxis
byHoangPhung15
 
Ascites
byHoangPhung15
 
Báng bụng
byHoangPhung15
 
Acute pancreatitis
byHoangPhung15
 
Diarrhea
byHoangPhung15
 
Blood transfusion complication
byHoangPhung15
 
Tilt table test - Nghiệm pháp bàn nghiêng
byHoangPhung15
 
Bệnh động mạch chủ
byHoangPhung15
 
Abdominal paracentesis - Chọc dò màng bụng
byHoangPhung15
 
Khí máu động mạch
byHoangPhung15
 
Tiếp cận ban đầu rối loạn nhịp tim nhanh
byHoangPhung15
 
ATRIOVENTRICULAR DISSOCIATION - Phân li nhĩ thất
byHoangPhung15
 
XỬ TRÍ TÌNH TRẠNG PHẢN VỆ TẠI KHOA LÂM SÀNG
byHoangPhung15
 
TIẾP CẬN THĂM KHÁM VÀ CHẨN ĐOÁN BỆNH LÍ LÁCH
byHoangPhung15
 

Recently uploaded

PPTX
RENAL DISEASES IN CHILDREN PPT BY DIVYAJYOTHI THOTA
bydivyajyothithota03
 
PPTX
SEMESTER 5 UNIT- 1 Difference of Children and adults.pptx
bysachin7989
 
PPTX
Declaration of Helsinki Basic principles in medical research ppt.pptx
byRanikonde
 
PPTX
How to Create & Configure Web Controllers in Odoo 18
byCeline George
 
PPTX
Time Series Analysis - Least Square Method Fitting a Linear Trend Equation
bySundar B N
 
PDF
ELEMENTS OF COMMUNITY SOCIOLOGY BSC NURSING.pdf
byJhasketan Kuanar
 
PPTX
Masterclass on Cybercrime, Scams & Safety Hacks.pptx
bykalkidirwhytap
 
PDF
LH_Lecture Note on Spices , AI And Importance in Human Life.pdf
bybisensharad
 
PDF
AI and ICT for Teaching and Learning, Induction-cum-Training Programme, 5th 8...
byProf. Vinod Kumar Kanvaria
 
PPTX
How to create a Pass-Fail quality check in Odoo 18 Quality
byCeline George
 
PPTX
kklklklklklklklk;lkpoipor[3rjdkjoe99759893058085
bypreetheshparmar
 
PDF
What is Digital Engineering, and how can it be used to enhance Project Manage...
byAssociation for Project Management
 
PPTX
English 5 Q3 W3 Describing the Character Traits Using Literal or Implied Mean...
byAizaPanganiban3
 
PDF
Digital Journalism Ethics 2025 materi for Regulation & Ethic Media
byAdePutraTunggali
 
PPTX
Time Series Analysis - Seasonal Indices by the Ratio to Trend Method
bySundar B N
 
PPTX
Time Series Analysis - Seasonal Indices Using Ratio to Moving Average Method
bySundar B N
 
PPTX
Capsules & Pellets -Industrial pharmacy UNIT-3, B Pharm III YEAR (V Semester)...
byARUN KUMAR
 
PPTX
Time Series Analysis - Weighted (Unequal) Moving Average Method
bySundar B N
 
PPTX
DEPED MEMORANDUM 089, 2025 PMES guidelines pptx
byRoseBubuli
 
PPTX
Time Series Analysis - Method of Simple Moving Average 3 Year and 4 Year Movi...
bySundar B N
 
RENAL DISEASES IN CHILDREN PPT BY DIVYAJYOTHI THOTA
bydivyajyothithota03
 
SEMESTER 5 UNIT- 1 Difference of Children and adults.pptx
bysachin7989
 
Declaration of Helsinki Basic principles in medical research ppt.pptx
byRanikonde
 
How to Create & Configure Web Controllers in Odoo 18
byCeline George
 
Time Series Analysis - Least Square Method Fitting a Linear Trend Equation
bySundar B N
 
ELEMENTS OF COMMUNITY SOCIOLOGY BSC NURSING.pdf
byJhasketan Kuanar
 
Masterclass on Cybercrime, Scams & Safety Hacks.pptx
bykalkidirwhytap
 
LH_Lecture Note on Spices , AI And Importance in Human Life.pdf
bybisensharad
 
AI and ICT for Teaching and Learning, Induction-cum-Training Programme, 5th 8...
byProf. Vinod Kumar Kanvaria
 
How to create a Pass-Fail quality check in Odoo 18 Quality
byCeline George
 
kklklklklklklklk;lkpoipor[3rjdkjoe99759893058085
bypreetheshparmar
 
What is Digital Engineering, and how can it be used to enhance Project Manage...
byAssociation for Project Management
 
English 5 Q3 W3 Describing the Character Traits Using Literal or Implied Mean...
byAizaPanganiban3
 
Digital Journalism Ethics 2025 materi for Regulation & Ethic Media
byAdePutraTunggali
 
Time Series Analysis - Seasonal Indices by the Ratio to Trend Method
bySundar B N
 
Time Series Analysis - Seasonal Indices Using Ratio to Moving Average Method
bySundar B N
 
Capsules & Pellets -Industrial pharmacy UNIT-3, B Pharm III YEAR (V Semester)...
byARUN KUMAR
 
Time Series Analysis - Weighted (Unequal) Moving Average Method
bySundar B N
 
DEPED MEMORANDUM 089, 2025 PMES guidelines pptx
byRoseBubuli
 
Time Series Analysis - Method of Simple Moving Average 3 Year and 4 Year Movi...
bySundar B N
 

Acute liver failure

  • 1.
    ACUTE LIVER FAILURE PHUNGHUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
  • 2.
  • 3.
    OVERVIEW ACUTE LIVER FAILURE PHUNGHUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
  • 4.
    DEFINITION • Coagulation abnormality(usually INR > 1.5) • Any degree of mental alteration (encephalopathy) • Virtually unique clinical feature: cerebral edema • Without preexisting cirrhosis • Illness of < 26 weeks’ duration • Exceptions: Wilson disease, vertically acquired HBV, autoimmune hepatitis, Budd- Chiari syndrome, HDV superinfection in patients with chronic HBV infection (present with ALF despite presence of unrecognized underlying chronic liver disease or cirrhosis) • Wendon J., Panel m., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081 • William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update“ • Larson A. M. (2012), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley-Blackwell, pp. 445-472
  • 5.
    CLASSIFICATION NOT particularly helpfulsince they do not have prognostic significance distinct from the cause of the illness • William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update“ • Willars C., Wendon J. (2014), Oh’s Intensive Care Manual, Andrew D Bersten , Neil Soni, Editors, Elsevier, pp. 501-519 7 days 21-28 days 26 weeks Hyperacute Acute Subacute Acetaminophen overdose, hepatitis A, and B,… Hepatitis ABE, idiosyncratic drug reactions,… Idiosyncratic drug reaction, seronegative hepatitis,… Interval from onset of disease (usually jaundice) to onset of encephalopathy
  • 6.
    Wendon J., Panelm., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
  • 7.
    Kuntz E., KuntzH.-D. (2008), Hepatology Textbook And Atlas, Springer, pp. 380-396
  • 8.
    Wendon J. (2015),Principles of Critical Care, Gregory A. Schmidt Jesse B. Hall, John P. Kress, Editor, McGraw Hill Education, pp. 1022-1026
  • 9.
    ETIOLOGY • Different etiologiestypically have a specifc time frame • Etiological diagnosis: strongest determinant of outcome1,2 1. William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update“ 2. Ziv Y. H., Collins M. H., Rothenberg M. E. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 1973-1988 3. Karvellas C. J., Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
  • 10.
    ETIOLOGY Drugs and toxins Viruses(Hepatotropic, Nonhepatotropic) Autoimmune diseases Metabolic diseases Vascular causes Infiltrative diseases Indeterminate (up to 10-15%*) (*) Spengler E., Fontana R. J. (2018), Handbook of Liver Disease, Lawrence S. Friedman , Paul Martin, Editors, Elsevier Saunders, pp. 18-33
  • 11.
    INFECTION • Hepatitis A,B (±D), E • Hemorrhagic fever viruses, CMV, HSV, EBV, adenovirus, VZV, Parvovirus B19 • Leptospira, listeria, malaria. M. tuberculosis, rickettsia, syphilis DRUGS/TOXINS • Dose-related: Acetaminophen, Carbon tetrachloride, Amanita poisoning, Bacillus cereus emetic toxin, Cyanobacteria microcystins, sulfonamide, tetracycline • Idiosyncratic: Reye’s syndrome (salicylic acid), Herbal medications, Prescription medications (i.e., isoniazid, halothane, troglitazone, bromfenac, valproic acid) VASCULAR • Budd–Chiari syndrome, Sinusoidal obstruction syndrome Ischemic (shock) liver METABOLIC/GENETIC • Galactosemia • Fructose intolerance • Tyrosinemia • Neonatal iron storage disease • Wilson disease • α1-Antitrypsin deficiency NEOPLASTIC • Metastases: breast, melanoma, lung, lymphoma PREGNANCY-RELATED • Acute fatty liver of pregnancy • HELLP syndrome MISCELLANEOUS • Autoimmune hepatitis • Heat stroke • Primary graft nonfunction in liver transplant recipients INDETERMINATE
  • 12.
    Ziv Y. H.,Collins M. H., Rothenberg M. E. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 1973-1988
  • 13.
    O’Grady J. (2016),Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1591-1602
  • 14.
    Larson A. M.(2012), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley-Blackwell, pp. 445-472
  • 15.
    Karvellas C. J.,Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
  • 16.
    • William M.,Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update“ • Larson A. M. (2012), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley-Blackwell, pp. 445-472 Drug classes associated with acute liver failure: Halothane, antituberculosis, anticonvulsants, antibiotics, antineoplastic, antiretroviral, MDMA (ectasy), NSAIDs
  • 17.
    O’Grady J. (2016),Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1591- 1602
  • 18.
    Karvellas C. J.,Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
  • 19.
    Murphy N. (2013),Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334.
  • 20.
    PATHOPHYSIOLOGY • Characteristics: • Massivehepatocyte necrosis • OR without histologic evidence of hepatocellular necrosis (acute fatty liver of pregnancy and Reye’s syndrome) • Abrupt loss in hepatic metabolic and immunologic functions  encephalopathy, coagulopathy, infection, multi-organ failure
  • 21.
    Ziv Y. H.,Collins M. H., Rothenberg M. E. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 1973- 1988
  • 22.
    Fontana R. J.,Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
  • 23.
    Fontana R. J.,Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
  • 24.
  • 25.
    Wendon J., Panelm., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
  • 26.
    APPROACH ACUTE LIVER FAILURE PHUNGHUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
  • 27.
    ALF DIAGNOSIS ESTABLISHED •Clinical or laboratory evidence of acute hepatitis • PT prolonged ≥ 4-6 seconds (INR ≥ 1.5) • Any evidence of altered sensorium ALF may be mistaken for cirrhosis and opportunity to be considered for transplantation losts
  • 28.
    Wendon J., Panelm., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
  • 29.
    HISTORY AND PHYSICALEXAMINATION • Review of possible exposures to viral infection and drugs (prescribed and OTC) or other toxins • History of abnormal LFTs • Mental status examination • Stigmata of chronic liver disease (palmar erythema, spider angiomata, caput medusae, gynecomastia, testicular atrophy, ascites/portal hypertension,…) • Jaundice • Right upper quadrant tenderness • Palpate and percuss area of liver • Enlarged = viral hepatitis, malignant infiltration, congestive heart failure, acute Budd-Chiari syndrome • Loss of liver volume due to massive hepatocyte loss
  • 30.
    LABORATORY EXAMINATION William M.,Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update"
  • 31.
    LABORATORY EXAMINATION • Completeblood count: • Leukocytosis: can be seen with acute hepatitis from any etiology (high risk for infection) • Thrombocytopenia: DIC, acute on chronic process. • Hemolytic anemia with Coombs (-): classically in fulminant Wilson disease. • Blood type and screen: two drawn independently needed for transplant evaluation, may require blood products as part of supportive care. • Acidosis,  arterial lactate = poor prognostic marker. • Arterial ammonia: >200µg/dL = strongly associated with cerebral herniation. • Toxicology screen (serum, urine): etiology of ALF and determine appropriateness of transplant candidacy (active drug abusers: not candidates for transplant) • Acetaminophen level
  • 32.
    LABORATORY EXAMINATION • Viralserologies: anti-HAV IgM, HBsAg, anti-HBc IgM, anti-HEV, anti-HCV, HSV-1 and HSV-2 IgM, VZV, CMV IgM • Ceruloplasmin: low or normal consistent with Wilson disease. Levels may be normal since it is an acute phase reactant. • Uric acid: if Wilson disease is suspected, levels may be low. • Autoimmune markers: ANA, ASMA, IgG levels. • Pregnancy test in females. • HIV status (HIV-1, HIV-2) • Amylase and lipase.
  • 33.
    LABORATORY EXAMINATION • Imagingtechniques • Liver US with Doppler • Abdominal CT scan with contrast or MRI with gadolinium (malignant infltration, Budd–Chiari syndrome, portal vein thrombosis) • Non-contrast head CT: rule out other causes of changes in mental status (not helpful to identify cerebral edema)
  • 34.
    Fontana R. J.,Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
  • 35.
    Murphy N. (2013),Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334.
  • 36.
    LIVER BIOPSY • Indications:limited • History of cancer or significant hepatomegaly: malignant infiltration should be excluded by imaging or liver biopsy • Performed preferably by a transjugular route, in a centre experienced in its use, and with access to a histopathologist with liver experience Wendon J., Panel m., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
  • 37.
    Wendon J., Panelm., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
  • 38.
    PROGNOSIS ACUTE LIVER FAILURE PHUNGHUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
  • 39.
    UNOS (United Networkfor Organ Sharing) Criteria for Status I Listing King’s College Criteria (KCH) MELD score (Model for End-stage Liver Disease) ALFSG (Acute Liver Failure Study Group Model) French Clichy Criteria APACHE II (Acute Physiology and Chronic Health Evaluation) scoring system
  • 40.
    Aditi A., CrippinJ. S. (2012), The Washington Manual of Critical Care, Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 376-386
  • 41.
    Wendon J., Panelm., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
  • 42.
    Fontana R. J.,Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
  • 43.
    Wendon J., Panelm., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
  • 44.
    Murphy N. (2013),Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334.
  • 45.
    OTHER INDICATORS OFPOOR PROGNOSIS • Etiology • Idiosyncratic drug injury • Acute hepatitis B (and other non-hepatitis A viral infections) • Autoimmune hepatitis • Mushroom poisoning • Wilson disease • Budd-Chiari syndrome • Indeterminate cause • Coma Grade on Admission: III or IV
  • 46.
    MANAGEMENT ACUTE LIVER FAILURE PHUNGHUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
  • 47.
    PRINCIPLES • Supportive care •Nutrition: Patients with ALF  resting energy expenditure  enteral or parenteral nutrition warranted • Venous thrombosis prophylaxis • Specific therapies • Treatment of complications • Liver transplantation: should be considered in all patients (King’s College criteria, modified King’s College criteria)
  • 48.
    Fontana R. J.,Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
  • 49.
    LIVER TRANSPLANTATION • Urgenthepatic transplantation: prognostic indicators suggest a high likelihood of death • Living donor or auxiliary liver transplantation: considered in the setting of limited organ supply (remains controversial) • King’s College Criteria or French Clichy Criteria • CONTRAINDICATIONS: • Severe cardiopulmonary disease or multiorgan failure • Septic shock • Extrahepatic malignant disease • Extensive thrombotic disease • Irreversible brain injury or brain death: CPP < 40 mmHg for >2 hours; Sustained ICP > 50 mmHg • Active substance abuse, repeated suicide attempts, or inadequate social support may preclude transplant candidacy
  • 50.
    Karvellas C. J.,Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
  • 51.
    William M., LeeM., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update"
  • 52.
    Fontana R. J.,Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
  • 53.
    LIVER SUPPORT SYSTEM •ARTIFICIAL SUPPORT = adsorben (plasmapheresis, molecular absorbents recirculation system-MARS) • BIOARTIFICIAL SUPPORT (HepatAssistTM (Arbios, formerly Circe, Waltham MA), extracorporeal liver support device (ELADTM; Vital Therapies, San Diego, CA), modular extracorporeal liver support system (MELSTM; Charité, Berlin, Germany), bioartificial liver support system (BLSSTM; Excorp Medical, Minneapolis MN), and the Amsterdam Medical Center bioartificial liver (AMCBALTM; AMC, Amsterdam, The Netherlands) Currently available liver support systems are not recommended outside of clinical trials; their future in the management of acute liver failure remains unclear William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update"
  • 54.
    Larson A. M.(2012), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley-Blackwell, pp. 445-472
  • 55.
    Larson A. M.(2012), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley-Blackwell, pp. 445-472
  • 56.
    Fontana R. J.,Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
  • 57.
    COMPLICATIONS ACUTE LIVER FAILURE PHUNGHUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
  • 58.
    HEPATIC ENCEPHALOPATHY/CEREBRAL EDEMA •Hepatic encephalopathy occurs in the presence or absence of cerebral edema • Cerebral edema and intracranial hypertension: most serious complications of ALF (> 20% of death)  uncal herniation, death (differentiated from that of cirrhosis) • Cerebral edema  ischemic + hypoxic brain injury  long-term neurological deficits in survivors • Risk of cerebral edema increases with the severity of encephalopathy •  arterial NH3 > 200 μmol/L = increased risk of developing ICH • Infections, hyperthermia:  risk of HE • Pathogenic mechanisms: not entirely understood (osmotic disturbances,  cerebral blood flow due to loss of cerebrovascular autoregulation, inflammation and/or infection) • Clinical signs: often unreliable and occur very late • Head CT: should be considered in grades 3 or 4 HE  cerebral edema or intracranial bleeding
  • 59.
    HIGH RISK FORCEREBRAL EDEMA • < 40 years of age • Very low or high JV O2 sat • Serum NH3 > 150 M • Severe hyponatremia <130 mmol/L • Grade 3/4 HE • Acute renal failure • Requiring vasopressors to maintain MAP • William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update“ • Murphy N. (2013), Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334. HEPATIC ENCEPHALOPATHY/CEREBRAL EDEMA
  • 60.
    Willars C., WendonJ. (2014), Oh’s Intensive Care Manual, Andrew D Bersten , Neil Soni, Editors, Elsevier, pp. 501-519
  • 61.
    Murphy N. (2013),Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334.
  • 62.
    Karvellas C. J.,Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
  • 63.
    Karvellas C. J.,Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301- 323
  • 64.
    Karvellas C. J.,Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
  • 65.
    Fontana R. J.,Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
  • 66.
    Karvellas C. J.,Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
  • 67.
    Willars C., WendonJ. (2014), Oh’s Intensive Care Manual, Andrew D Bersten , Neil Soni, Editors, Elsevier, pp. 501-519 CCP = MAP - ICP
  • 68.
    Karvellas C. J.,Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
  • 69.
    Ziv Y. H.,Collins M. H., Rothenberg M. E. (2016), Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 1973-1988
  • 70.
    MANAGEMENT (1) • Consideradmitted to ICU ± transfer to transplant center • Head of bed at 30 degrees, correct factors  ICP (quiet room with minimal suctioning/noxious stimuli, intratracheal lidocaine before respiratory suctioning, treat agitation, monitor for and treat seizures, correct hypoxemia, volume overload, hypotension) • Intracranial pressure monitoring; Neurological checks q4h • Avoid narcotics and sedatives (if patient agitated  more important to keep patient calm) • Seizures ( ICP, cerebral hypoxia  cerebral edema): • Phenytoin: treatment (loading 20 mg/kg with dose adjusted in the setting of renal failure followed by maintenance dosing) • Prophylactic phenytoin: NOT recommended • Short-acting BZD: phenytoin-refractory cases HEPATIC ENCEPHALOPATHY/CEREBRAL EDEMA
  • 71.
    Fontana R. J.,Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
  • 72.
    O’Grady J. (2016),Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1591-1602
  • 73.
    Murphy N. (2013),Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334.
  • 74.
    MANAGEMENT (2) • Mannitol(0.5g/kg IV; repeated 1–2 times as needed if serum osmolality < 320 mosm/L): contraindicated in renal failure • Prophylactic induction of hypernatremia = hypertonic saline (to a sodium level of 145-155 mEq/L): recommended for highest risk of cerebral edema • Lactulose: ± • Early stages of encephalopathy (orally or rectally) to effect a bowel purge (should not be administered to the point of diarrhea) • May lead to colonic distension = unfavorable in transplant setting) • Endotracheal intubation: high-grade HE (grade III or IV) • Corticosteroids: should NOT be used to control elevated ICP in patients with ALF • Hyperventilation: NO role HEPATIC ENCEPHALOPATHY/CEREBRAL EDEMA
  • 75.
    William M., LeeM., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update"
  • 76.
    Gonzalez S. A.,Keeffe E. B. (2012), Handbook of Liver Disease, Lawrence S. Friedman , Emmet B. Keeffe, Editors, Elsevier Saunders, pp. 20-33
  • 77.
    Aditi A., CrippinJ. S. (2012), The Washington Manual of Critical Care, Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 376-386
  • 78.
    COAGULOPATHY • Mechanism: • Lossof hepatocellular function   synthesis of coagulation (Factor II, V, VII, IX, and X) and fibrinolysis factors and inhibitors +  breakdown of activated factors • Abnormalities in platelet count ( thrombopoietin), function, and morphology • Consumption of clotting factors and platelets • GI bleeding: from superfcial gastric erosions and stress ulcers • Key feature of ALF + important prognostic indicator • Risk of severe hemorrhage: 10%1,2 (gastrointestinal tract, nasopharynx, lungs, puncture sites, and retroperitoneum) 1. Spengler E., Fontana R. J. (2018), Handbook of Liver Disease, Lawrence S. Friedman , Paul Martin, Editors, Elsevier Saunders, pp. 18-33 2. Hay J. E. (2010), Practical Gastroenterology and Hepatology - Liver and Biliary Disease, Nicholas J. Talley, Keith D. Lindor, Hugo E. Vargas, Editors, Blackwell Publishing, pp. 113-123.
  • 79.
    COAGULOPATHY MANAGEMENT • Expectant (thrombogenicand thrombolytic pathways that may balance each other!) • Vitamin K 10 mg (IV or SC): 3 days for all patients • Platelet transfusions, FFP, cryoprecipitate: • Active bleeding • Need for invasive procedures (liver biopsy, placement of an intracranial monitoring device, CVC,…) Goal: PLT > 50.000/mm3, INR < 1.5, Fibrinogen > 100 mg/dL • Recombinant factor VII: may be used with caution and only under certain conditions • Prophylactic acid suppression = H2RA or PPIs (1st line), sucralfate (2nd line): ICU patient • Plasma exchange may also be used to correct coagulopathy (*) William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update"
  • 80.
    Karvellas C. J.,Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323 Model of rebalanced hemostasis in acute liver failure
  • 81.
    Fontana R. J.,Bari K. (2018), Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431.
  • 82.
    INFECTION • One ofthe major causes of death • 80% of patients with FHF* • Mechanism: • Kupffer cell malfunction   clearance of gut-derived bacteria + endotoxin • Impaired uptake   fibronectin (important co-factor made by the liver needed for opsonization) • Neutrophil malfunction (phagocytosis, opsonization, mobility): may be related to  serum complement levels • Defective lymphocyte function  cell-immunity • NOT ONLY from gut-derived organisms but also from Gram-positive organisms (*) Aditi A., Crippin J. S. (2012), The Washington Manual of Critical Care, Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 376-386
  • 83.
    Karvellas C. J.,Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
  • 84.
    Karvellas C. J.,Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
  • 85.
    INFECTION • Periodic surveillancecultures (detect bacterial and fungal pathogens as early as possible) • Antibiotic treatment: • Low threshold for initiation of broad-spectrum coverage should be maintained = surveillance culture results or at earliest sign of active infection or deterioration (progression to high grade HE or elements of the SIRS) • Empiric: 3rd generation cephalosporin/FQ + vancomycin • Systemic antifungal therapy (amphotericin, fluconazole, or caspofungin): prolonged antibiotics, MICU stay, renal failure, emergent transplantation • Prophylactic antibiotics and antifungals: NOT been shown to improve overall outcomes in ALF • Granulocyte colony-stimulating factor (GCSF): ±
  • 86.
    CARDIOVASCULAR DYSFUNCTION • Lowsystemic and pulmonary vascular resistance • Compensatory increase in cardiac output • Increased metabolic rate • Abnormal oxygen transport and uptake • Impaired responses to adrenocorticotropic hormone (ACTH) # septic shock pathologic state
  • 87.
    Karvellas C. J.,Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
  • 88.
    CARDIOVASCULAR DYSFUNCTION MANAGEMENT • Supplementaloxygen. • Hemodynamic monitoring of central pressures • Blood transfusions if needed ( oxygen carrying capacity) • Fluid resuscitation and maintenance of adequate intravascular volume • Blood pressure support: • Systemic vasopressor support (norepinephrine or dopamine)  maintain MAP ≥ 75mmHg1. • Dobutamine: considered if severe LV dysfunction (may worsen hypotension) • Vasopressin: should be AVOIDED (effects on  cerebral blood flow and intracranial hypertension) • Hydrocortisone trial (200-300 mg/day): persistent hypotension despite fluid resusciation and vassopressor (not reduce mortality but does  vasopressor requirements2) 1. William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update“ 2. Wendon J., Panel m., Cordoba J., et al. (2017), J Hepatol, 66 (5), pp. 1047-1081
  • 89.
    RENAL FAILURE • Pathophysiology •Direct nephrotoxicity (eg, Acetaminophen, etc.) • Hepatorenal syndrome (intense renal vasoconstriction  systemic vasodilation) • Hypovolemia • Impaired hepatic urea production  underestimation of renal impairment • Key early prognostic indicator • MANAGEMENT: • Fluid resuscitation and maintenance of adequate intravascular volume • Avoidance of nephrotoxic agents • Dialysis support when needed: continuous mode (CVVH – avoid heparin if possible) rather than an intermittent mode (limit fluctuations in systemic pressure and cerebral perfusion pressure)
  • 90.
    Karvellas C. J.,Stravitz R. T. (2018), Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323
  • 91.
    METABOLIC DERANGEMENT • Hypoglycemia:defective gluconeogenesis +  hepatic glycogen production + inadequate hepatic uptake of insulin • Hypophosphatemia: ATP consumption/rapid hepatocyte regeneration +  urinary loss • Acidosis (important predictor of mortality) and alkalosis (hyperventilation) • Electrolyte and metabolic derangements: contribute to progressive HE +  risk of cerebral edema
  • 92.
    PREVENTION ACUTE LIVER FAILURE PHUNGHUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
  • 93.
    • Before onsetof chemotherapy or immunosuppressive therapy + HBsAg (+) • Prophylactic oral nucleoside or nucleotide antiviral therapy (several weeks before) • Antiviral maintenance: • HBV-DNA < 2000 UI/mL: 6 months after completion of chemotherapy or immunosuppressive therapy • HBV-DNA > 2000 UI/mL: until HBV DNA undetectable + ALT levels normalized • Limiting availability of bulk acetaminophen • Psychiatric assistance: depression and have attempted suicide • Patient education: accidental overdose (*) Bansal M. B. (2014), Mount Sinai Expert Guides - Hepatology, Jawad Ahmad, Scott L. Friedman, Henryk Dancygier, Editors, Wiley Blackwell, pp. 280-293.
  • 94.
    O’Grady J. (2016),Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1591-1602
  • 95.
    O’Grady J. (2016),Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1591-1602
  • 96.
    REFERENCES ACUTE LIVER FAILURE PHUNGHUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018
  • 97.
    1. Fontana R.J., Bari K. (2018), "Acute Liver Failure", Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, K. Rajender Reddy, Editors, Wiley-Blackwell, pp. 411-431. 2. Larson A. M. (2012), "Acute Liver Failure", Schiff’s Diseases of The Liver, Eugene R. Schiff, Willis C. Maddrey, Michael F. Sorrell, Editors, Wiley-Blackwell, pp. 445-472. 3. Aditi A., Crippin J. S. (2012), "Fulminant Hepatic Failure", The Washington Manual of Critical Care, Marin H. Kollef , Warren Isakow, Editors, Lippincott Williams & Wilkins, pp. 376-386. 4. Bansal M. B. (2014), "Acute Liver Failure", Mount Sinai Expert Guides - Hepatology, Jawad Ahmad, Scott L. Friedman, Henryk Dancygier, Editors, Wiley Blackwell, pp. 280-293. 5. Hay J. E. (2010), "Acute Liver Failure", Practical Gastroenterology and Hepatology - Liver and Biliary Disease, Nicholas J. Talley, Keith D. Lindor, Hugo E. Vargas, Editors, Blackwell Publishing, pp. 113-123. 6. Karvellas C. J., Stravitz R. T. (2018), "Acute Liver Failure", Zakim and Boyer’s Hepatology: A Textbook of Liver Disease, Arun J. Sanyal, et al., Editors, Elsevier, pp. 301-323. 7. Kuntz E., Kuntz H.-D. (2008), "Acute and chronic liver insufficiency", Hepatology Textbook And Atlas, Springer, pp. 380-396. 8. Murphy N. (2013), "Diagnosis and Management of Liver Failure in the Adult", Critical Care Medicine - Principles Of Diagnosis And Management In The Adult, Joseph E. Parrillo , R. Phillip Dellinger, Editors, Elsevier Saunders, pp. 1309-1334. 9. O’Grady J. (2016), "Acute Liver Failure", Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, Editors, Elsevier Saunders, pp. 1591-1602. 10. Spengler E., Fontana R. J. (2018), "Acute liver failure", Handbook of Liver Disease, Lawrence S. Friedman , Paul Martin, Editors, Elsevier Saunders, pp. 18-33. 11. Wendon J. (2015), "Acute Liver Failure", Principles of Critical Care, Gregory A. Schmidt Jesse B. Hall, John P. Kress, Editor, McGraw Hill Education, pp. 1022-1026.
  • 98.
    12. Wendon J.,Panel m., Cordoba J., et al. (2017), "EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure", J Hepatol, 66 (5), pp. 1047-1081. 13. Willars C., Wendon J. (2014), "Liver failure", Oh’s Intensive Care Manual, Andrew D Bersten , Neil Soni, Editors, Elsevier, pp. 501-519. 14. William M., Lee M., Larson A. M., et al. (2011), "AASLD position paper: The management of acute liver failure: Update". 15. Ziv Y. H., Collins M. H., Rothenberg M. E. (2016), "Acute liver failure", Yamada’s Textbook of Gastroenterology, Daniel K. Podolsky, Michael Camilleri, J. Gregory Fitz, Editors, Wiley Blackwell, pp. 1973-1988.
  • 99.
    ACUTE LIVER FAILURE PHUNGHUY HOANG, MD Resident in Internal Medicine Pham Ngoc Thach University of Medicine January, 2018