Acute Liver Failure

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CLINICAL DESCRIPTION

Acute liver failure (ALF) manifests with rapid deterioration in the synthetic and excretory liver functions with impaired coagulation (INR >1.5) and signs of encephalopathy in adults and pediatrics. ALF may lead to the following complications: Hypoglycemia, electrolyte abnormalities, acidosis, renal impairment, ascites, sepsis.

Acute Liver failure can be caused by the following:

  • Infection (acute viral hepatitis, herpes simplex virus, CMV, HIV, TORCH)
  • Autoimmune hepatitis
  • Alcoholic hepatitis
  • Drugs and Toxins (Paracetamol, ART, TB drugs especially isoniazid, NSAIDS, statins, antibiotics (amoxicillin, sulfonamides, tetracyclines), amanita mushroom
  • Metabolic diseases
  • Pregnancy: fatty liver, HELLP syndrome

CLINICAL FEATURES

SIGNS AND SYMPTOMS 

  • Jaundice
  • Fever
  • Malaise
  • Altered level of consciousness
  • Right upper quadrant pain
  • Hepatomegaly
  • Bleeding tendencies

INVESTIGATIONS

  • Random blood glucose
  • Liver function test
  • Hepatitis serology
  • Viral serology
  • HIV test
  • Urea, electrolytes and Creatinine
  • Clotting profile
  • Drug levels
  • Ferritin
  • Serum copper
  • Serum iron

TREATMENT 

NON-PHARMACOLOGICAL

  • Stop offending drugs or alcohol
  • Acute: ABCD approach
  • Treat hypoglycemia according to protocol
  • Restrict dietary protein
  • Monitor urine output
  • Counsel parents

PHARMACOLOGICAL

Coagulotherapy 

Adults: 

  • Vitamin K 10mg IV for 3 days, consider giving FFP 3 units if bleeding actively

Paediatrics:

  • Vitamin K 5-10mg/kg IV daily (DO NOT GIVE IM)
  • Fresh frozen plasma 10ml/kg IV
  • Cryoprecipitate, platelets or factor VII concentrate        

 

Cerebral oedema in acute liver failure 

Adults:

  • Neuroprotective measures
  • Mannitol 0.5-2g /kg IV over 1 hour (repeated every 6 to 8 hours for maximum 48 hours)
  • Don’t repeat if no response

Paediatrics:                         

  • Two thirds of maintenance fluids                                      
  • Neuroprotective measures  
  • Mannitol 0.5-2g /kg IV over 1 hour (repeated every 6 to 8 hours for maximum 48 hours)
  • Don’t repeat if no response.

 

Hepatic Encephalopathy

Adults:

  • Give Lactulose 30mg po every 4hrs – aim for 2-4 bowel movements/day OR Neomycin 1g every 6hrs for 7 days

In Pediatrics:

  • Give oral Neomycin 1g/m2 4-6hourly or Kanamycin IV STAT dose
    • Neonate <1-week 15mg/kg
    • 1 week – 10 years 25mg/kg
    • >10 years 20mg/kg
  • Oral Lactulose 1ml/kg hourly until child has diarrhoea then 6 to 8 hourly.

 

Sepsis in liver failure

Adults:

  • Give Ceftriaxone 1g every day IV for 5 days

 

Hypoglycemia in liver failure 

Adults: 

  • 50mls 50% Dextrose IV push, maintenance with 10% Dextrose 1 litre/12 hours

Pediatrics:

  • Manage hypoglycemia according to protocol. Avoid sedatives