Acute liver failure: updates in pathogenesis and management (original) (raw)

Acute liver failure (ALF) is a life-threatening illness precipitated by an acute liver injury in patients with no pre-existing liver disease. Acute viral hepatitis and drug-induced liver injury account for the majority of cases, the clinical course characterised by the development of coagulopathy and hepatic encephalopathy (HE), often progressing to multi-organ disease which is associated with high fatality rates. The outcomes have improved significantly over time with improving standards of organ system support and access to liver transplantation for the very sick. The King's College Hospital criteria (KCH) is the most commonly used tool for determination of prognosis and consideration for transplantation. Prompt diagnosis, immediate initiation of supportive care and aetiology-specific treatment, where applicable, and early discussions and transfer to transplant centre are keys to successful outcome. KEYWORDS Acute liver failure, fulminant hepatitis, critical care, hepatic encephalopathy, multi-organ failure, intensive care, liver transplantation. DEFINITION AND CLASSIFICATION Acute liver failure (ALF) is a rare, life-threatening illness, triggered by a de novo liver injury to a previously healthy liver, frequently progressing within hours and weeks to multisystem involvement and failure. Coagulation abnormalities of liver origin (elevated prothrombin time (PT) or International Normalised Ratio (INR) above 1.5) and mental alterations due to hepatic encephalopathy (HE) are the key defining clinical criteria required to make a diagnosis. ALF is a specific clinical entity in terms of the clinical phenotype, disease course, prognosis, and eligibility for emergency liver transplantation. This must be distinguished from secondary liver injury in sepsis or congestive cardiac disease or failure following major liver resection, none of which would qualify as ALF and would not be indications for emergency liver transplantation. Conversely, acute presentations of Wilson's disease, acute Budd-Chiari syndrome and some cases of autoimmune hepatitis may have undiagnosed chronic liver involvement but are treated as ALF because of the poor prognosis without transplantation in these conditions and clinical features consisting predominantly of coagulopathy and HE.