Acute liver failure natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2]
Overview
Acute liver failure is a sudden and severe loss of liver function with evidence of encephalopathy and coagulopathy with elevated prothrombin time (PT) and (INR) in a person without preexisting liver disease. The commonly used time duration for an acute liver disease is < 26 weeks. Acute liver failure can be hyperacute, acute or subacute depending upon how long the patient has signs and symptoms of liver failure. If left untreated, patients with acute liver failure can eventually progress to develop confusion, comatose state, and death. Common complications of acute liver failure are hepatic encephalopathy, cerebral edema, coagulopathy, a systemic inflammatory response syndrome, acute renal failure and acute pulmonary failure. The important factors in determining the prognosis of acute liver failure include patients' age, the severity of encephalopathy and the underlying cause of acute liver failure. The commonly used prognostic indicators to predict mortality in patients with acute liver failure and to identify patients who are likely to benefit from liver transplantation include kings college criteria ( use for liver transplantation ) and model for end-stage liver disease (MELD) score (to predict mortality in patients with chronic and acute liver disease).
Natural History
Acute liver failure is a sudden and severe loss of liver function with evidence of encephalopathy and coagulopathy with elevated prothrombin time (PT) and (INR) in a person without preexisting liver disease. The commonly used time duration for an acute liver disease is < 26 weeks.[1]
- Acute liver failure can be hyperacute, acute or subacute depending upon how long the patient has signs and symptoms of liver failure.
- The natural history of acute liver failure depends on the etiology but generally, cerebral edema mainly presents in hyperacute or acute liver failure, whereas renal shutdown and portal hypertension are the main concerns in the subacute liver failure.
- If left untreated, patients with acute liver failure may initially having nonspecific symptoms such as anorexia, fatigue, nausea or vomiting, diffuse or right upper quadrant abdominal pain or jaundice and can eventually progress to develop confusion and the comatose state and death. A systemic inflammatory response syndrome may also develop. Acute renal failure occurs in up to 50% of cases. The condition can also worsen to the point of causing hemodynamic and cardiovascular compromise.
- The timely recognition and treatment of some of the causes of acute liver failure can reverse the condition and may improve the patient's prognosis. The timely evaluation can also help in identifying patients who may require liver transplantation.
- In acetaminophen toxicity patients, the time duration between acetaminophen ingestion and treatment with acetylcysteine greatly influence the outcome.
Complications
Complications that can develop as a result of acute liver failure are:[2][3][4][5][6][7].[8][9][10]. There is also abnormal oxygen transport and utilization. Although delivery of oxygen to the tissues is adequate, there is a decrease in tissue oxygen uptake, resulting in tissue hypoxia and lactic acidosis[11][12].
- Cerebral edema
- Encephalopathy
- Coagulopathy
- Renal failure
- Renal failure
- Systemic inflammatory response
- Metabolic derrangements
- Pulmonary complications
Prognosis
- The important factors in determining the prognosis of acute liver failure include patients' age, the severity of encephalopathy and the underlying cause of acute liver failure.[13][14][15][16][17][18]
Several prognostic scoring systems to predict mortality in patients with acute liver failure and to identify patients who are likely to benefit from liver transplantation include:
- King's College Criteria ( most widely use for liver transplantation)
- Model for End-Stage Liver Disease (MELD) score (use to predict mortality in patients with chronic and acute liver disease)
- Sequential Organ Failure Assessment (SOFA score)
- Clichy criteria
- Acute Liver Failure Study Group (ALFSG) index
References
- ↑ Bower WA, Johns M, Margolis HS, Williams IT, Bell BP (2007). "Population-based surveillance for acute liver failure". Am J Gastroenterol. 102 (11): 2459–63. doi:10.1111/j.1572-0241.2007.01388.x. PMID 17608778.
- ↑ Kumar R, Shalimar. Bhatia V, Khanal S, Sreenivas V, Gupta SD; et al. (2010). "Antituberculosis therapy-induced acute liver failure: magnitude, profile, prognosis, and predictors of outcome". Hepatology. 51 (5): 1665–74. doi:10.1002/hep.23534. PMID 20196116.
- ↑ Riordan SM, Williams R (1997). "Treatment of hepatic encephalopathy". N. Engl. J. Med. 337 (7): 473–9. doi:10.1056/NEJM199708143370707. PMID 9250851.
- ↑ Lee WM (1993). "Acute liver failure". N. Engl. J. Med. 329 (25): 1862–72. doi:10.1056/NEJM199312163292508. PMID 8305063.
- ↑ Muñoz SJ (1993). "Difficult management problems in fulminant hepatic failure". Semin. Liver Dis. 13 (4): 395–413. PMID 8303321.
- ↑ Hazell AS, Butterworth RF (1999). "Hepatic encephalopathy: An update of pathophysiologic mechanisms". Proc. Soc. Exp. Biol. Med. 222 (2): 99–112. PMID 10564534.
- ↑ Larsen FS, Wendon J (2002). "Brain edema in liver failure: basic physiologic principles and management". Liver Transpl. 8 (11): 983–9. doi:10.1053/jlts.2002.35779. PMID 12424710.
- ↑ Armstrong IR, Pollok A, Lee A (1993). "Complications of intracranial pressure monitoring in fulminant hepatic failure". Lancet. 341 (8846): 690–1. PMID 8095592.
- ↑ Schmidt LE, Larsen FS (2006). "hyperlactatemia". Crit. Care Med. 34 (2): 337–43. PMID 16424712.
- ↑ Harry R, Auzinger G, Wendon J (2002). "The clinical importance of adrenal insufficiency in acute hepatic dysfunction". Hepatology. 36 (2): 395–402. doi:10.1053/jhep.2002.34514. PMID 12143048.
- ↑ Bihari D, Gimson AE, Waterson M, Williams R (1985). "Tissue hypoxia during fulminant hepatic failure". Crit. Care Med. 13 (12): 1034–9. PMID 3933911.
- ↑ Trewby PN, Warren R, Contini S; et al. (1978). "Incidence and pathophysiology of pulmonary edema in fulminant hepatic failure". Gastroenterology. 74 (5 Pt 1): 859–65. PMID 346431.
- ↑ Dhiman RK, Seth AK, Jain S, Chawla YK, Dilawari JB (1998). "Prognostic evaluation of early indicators in fulminant hepatic failure by multivariate analysis". Dig. Dis. Sci. 43 (6): 1311–6. PMID 9635624.
- ↑ Huo TI, Wu JC, Sheng WY, Chan CY, Hwang SJ, Chen TZ, Lee SD (1996). "Prognostic factor analysis of fulminant and subfulminant hepatic failure in an area endemic for hepatitis B". J. Gastroenterol. Hepatol. 11 (6): 560–5. PMID 8792311.
- ↑ Takahashi Y, Kumada H, Shimizu M, Tanikawa K, Kumashiro R, Omata M, Ehata T, Tsuji T, Ukida M, Yasunaga M (1994). "A multicenter study on the prognosis of fulminant viral hepatitis: early prediction for liver transplantation". Hepatology. 19 (5): 1065–71. PMID 8175127.
- ↑ Lake JR, Sussman NL (1995). "Determining prognosis in patients with fulminant hepatic failure: when you absolutely, positively have to know the answer". Hepatology. 21 (3): 879–82. PMID 7875687.
- ↑ Pauwels A, Mostefa-Kara N, Florent C, Lévy VG (1993). "Emergency liver transplantation for acute liver failure. Evaluation of London and Clichy criteria". J. Hepatol. 17 (1): 124–7. PMID 8445211.
- ↑ Rutherford A, King LY, Hynan LS, Vedvyas C, Lin W, Lee WM, Chung RT (2012). "Development of an accurate index for predicting outcomes of patients with acute liver failure". Gastroenterology. 143 (5): 1237–43. doi:10.1053/j.gastro.2012.07.113. PMC 3480539. PMID 22885329.