DOCSLIB.ORG

Managing Liver Failure D a Kelly

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Managing Liver Failure D a Kelly 660 Postgrad Med J: first published as 10.1136/pmj.78.925.660 on 1 November 2002. Downloaded from BEST PRACTICE Managing liver failure D A Kelly ............................................................................................................................. Postgrad Med J 2002;78:660–667 Liver disease is rare in childhood, but important new Clinical presentation developments have altered the natural history and The clinical presentation depends on the aeti- ology of acute liver failure but the presentation outcome. It is important that clinicians are aware of may either be acute, within days, or prolonged to these diseases and their management. Acute liver failure 10 weeks if due to metabolic liver disease. The is most often due to viral hepatitis, paracetamol extent of jaundice and encephalopathy is variable in the early stages, but all children have coagu- overdose, or inherited metabolic liver disease. The lopathy. Encephalopathy is particularly difficult to clinical presentation includes jaundice, coagulopathy, diagnose in neonates. Vomiting and poor feeding and encephalopathy. Early diagnosis is necessary to are early signs, while irritability and reversal of day/night sleep patterns indicates more estab- prevent complications such as cerebral oedema, lished hepatic encephalopathy. In older children gastrointestinal bleeding, and renal failure. Early encephalopathy may present with aggressive supportive management, in particular intravenous behaviour or convulsions. N-acetylcysteine, may be effective but liver Neonatal acute liver failure transplantation is usually the definitive treatment and The commonest cause of acute liver failure in thus early referral to a specialist unit for liver neonates is septicaemia secondary to Escherichia coli, Staphylococcus aureus, or herpes simplex (box 1 transplantation is mandatory. Chronic liver failure may and table 1). Other causes include adenovirus, be due to unresolved neonatal liver disease, either echovirus, and Coxsackie virus. Acute liver failure secondary to hepatitis B usually presents at about inherited biliary hypoplasia or extrahepatic biliary 12 weeks of age while hepatitis A is rare in atresia, while in older children, autoimmune liver neonates. Hepatitis C does not cause acute liver disease or cystic fibrosis are the commonest causes. failure in neonates. Treatment includes specific medication, nutritional Hepatitis B support, and liver transplantation, which now has a Hepatitis B is vertically transmitted during pregnancy or delivery. The transmission rate is 90% survival with good quality life. http://pmj.bmj.com/ approximately 70% in mothers who are hepatitis .......................................................................... B surface antigen and hepatitis B e antigen posi- tive. Most infected infants will become asympto- ACUTE LIVER FAILURE matic carriers. In contrast, infants born to moth- Acute liver failure or fulminant hepatitis is rare ers who are hepatitis B e antigen negative have a in childhood, but has a mortality of 70% without high risk of developing fulminant hepatitis appropriate management and/or liver transplan- within the first 12 weeks of life due the transmis- sion of a pre-core mutant hepatitis virus from tation. Fulminant hepatic failure is defined as on September 28, 2021 by guest. Protected copyright. the development of hepatic necrosis with mother to child.23 Both the development of the encephalopathy within eight weeks of the onset carrier state and fulminant hepatitis B may be of liver disease. This definition is not useful for prevented by vaccination of all infants of hepati- paediatric acute liver failure as the clinical tis B carrier mothers, irrespective of their e presentation may be prolonged particularly if antigen status. secondary to autoimmune or metabolic liver disease.1 Neonatal haemochromatosis The acute liver damage may be secondary to a Neonatal haemochromatosis is a rare disorder, virus, drug, or toxin or immune mediated attack. which is associated with iron accumulation in The underlying mechanism is unknown but is liver, pancreas, heart, and brain. It is not known multifactorial and depends on the age, sus- whether the disease is inherited with autosomal ....................... ceptibility of the patient, and the extent of recessive inheritance or is an acquired defect of hepatic injury. The main pathological features iron handling in pregnancy. Clinical presentation Correspondence to: may be within hours or weeks of birth with jaun- include severe hepatic necrosis, loss of hepatic Professor Deirdre A Kelly, dice, hypoglycaemia, and severe coagulopathy. architecture, and absence of hepatic regenera- Liver Unit, Birmingham Encephalopathy, although present may not be Children’s Hospital NHS tion. Trust, Steelhouse Lane, The aetiology of acute liver failure varies Birmingham B4 6NH, UK; Deirdre.Kelly@ depending on the age of the child (box 1). In ................................................. bhamchildrens.wmids.nhs.uk neonates, inherited metabolic liver disease or Abbreviations: FIC, familial intrahepatic cholestasis; infection is likely while viral hepatitis, auto- Submitted 27 May 2002 NTBC, 2 (2 nitro-4-trifluoromethylbenzoyl)-1, Accepted 19 June 2002 immune liver disease, or drug induced liver 3-cyclohexenedione; TIPSS, transjugular intrahepatic ....................... failure are common in older children. portosystemic stent shunt www.postgradmedj.com Managing liver failure 661 Postgrad Med J: first published as 10.1136/pmj.78.925.660 on 1 November 2002. Downloaded from Box 1: Aetiology of acute liver failure Box 2: Supportive management of fulminant hepatitis Neonate/infant up to 6 months • No sedation except for procedures. • Infection: septicaemia, hepatitis B, adenovirus, echovirus, • Monitor: neurological observations 4–6 hourly, gastric pH Coxsackie B. (>5), blood glucose (>4 mmol/l), acid-base/electrolytes, • Metabolic: neonatal haemochromatosis, tyrosinaemia type prothrombin time, partial thromboplastin time. I, mitochondrial disorders, fatty acid oxidation defects. • Fluid balance: 75% maintenance. • Poisoning: paracetamol. Maintain circulating volume with colloid/fresh frozen • Familial haemophagocytic syndrome. plasma. Consider: frusemide infusion, haemofiltration. Children >6 months • Coagulation support (fresh frozen plasma, cryoprecipitate). • Viral hepatitis: hepatitis A/B/E/non-A-G, Epstein-Barr • Drugs: vitamin K (2–10 mg), ranitidine (3 mg/kg), virus, parvovirus B19. sucralfate (2–4 g/day), lactulose (5–20 ml/day), • Autoimmune type I or II. N-acetylcysteine (70 mg/kg/6 hour), +/- broad spectrum • Drug induced: paracetamol overdose, sodium valproate, antibiotics, fluconazole. carbamazepine, isoniazid, halothane. • Nutrition: enteral feeding (1–2 g protein/day), parenteral • Metabolic: Wilson’s disease, Alpers disease. nutrition if ventilated. obvious. The diagnosis is suggested by raised ferritin levels coagulopathy, encephalopathy, ascites, and occasionally hyper- (2000–3000 µg/l) and confirmed by demonstrating a high insulinism. The diagnosis is based on increased plasma serum iron with hypersaturation of iron binding capacity tyrosine, phenylalanine, methionine and confirmed by identi- (95%–105%) and the demonstration of extrahepatic haemosi- fying a toxic metabolite, succinylacetone in the urine, or by derosis. Because of the severe coagulopathy liver biopsy is enzyme analysis of skin fibroblasts. Management includes usually contraindicated but extrahepatic siderosis may be supportive management of acute liver failure (box 2) and with demonstrated in salivary glands obtained by lip biopsy or the 2 (2 nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexenedione 5 demonstration of iron accumulation in pancreas and brain on (NTBC), which prevents the formation of toxic metabolites magnetic resonance imaging. Intensive supportive manage- and allows hepatic regeneration. Children who fail to respond 6 ment of the liver failure and an antioxidant cocktail (boxes 2 to NTBC should be offered liver transplantation. and 3) may be effective if begun within 24–48 hours of birth in milder cases but liver transplantation is usually required.4 Mitochondrial disorders Mitochondrial disorders present with acute liver failure in the Tyrosinaemia type I context of multiorgan disease. There are many different clini- Tyrosinaemia type I is an autosomal recessive disorder cal phenotypes and modes of inheritance including transmis- secondary to deficiency of fumaryl acetoacetase which sion through maternal DNA. The disorders include deficien- prevents the metabolism of tyrosine leading to the accumula- cies of the electron transport chain enzymes or depletion of tion of toxic metabolites, which damage liver, kidneys, heart, mitochondrial DNA. Neonates and infants present with jaun- and brain. Infants present between 1 and 6 months of age dice, coagulopathy, and neurological features very similar to with acute liver failure with mild jaundice, hypoglycaemia, hepatic encephalopathy and multiorgan failure (cardiac, renal, bone marrow). Infants have metabolic acidosis with a raised blood lactate. Other useful investigations are an http://pmj.bmj.com/ Table 1 Investigations for acute and chronic liver increased plasma 3-hydroxybutyrate-acetoacetate ratio (>2) failure in children or detection of abnormal organic acids such as urinary 3-methylglutaconic acid. Evidence of multiorgan involvement Investigations is confirmed by muscle biopsy which may demonstrate abnor- Infection mal mitochondria while an increased
Load more

Recommended publications
  • Acute Liver Failure J G O’Grady
    148 Postgrad Med J: first published as 10.1136/pgmj.2004.026005 on 4 March 2005. Downloaded from REVIEW Acute liver failure J G O’Grady ............................................................................................................................... Postgrad Med J 2005;81:148–154. doi: 10.1136/pgmj.2004.026005 Acute liver failure is a complex multisystemic illness that account for most cases, but a significant number of patients have no definable cause and are evolves quickly after a catastrophic insult to the liver classified as seronegative or of being of indeter- leading to the development of encephalopathy. The minate aetiology. Paracetamol is the commonest underlying aetiology and the pace of progression strongly cause in the UK and USA.2 Idiosyncratic reac- tions comprise another important group. influence the clinical course. The commonest causes are paracetamol, idiosyncratic drug reactions, hepatitis B, and Viral seronegative hepatitis. The optimal care is multidisciplinary ALF is an uncommon complication of viral and up to half of the cases receive liver transplants, with hepatitis, occurring in 0.2%–4% of cases depend- ing on the underlying aetiology.3 The risk is survival rates around 75%–90%. Artificial liver support lowest with hepatitis A, but it increases with the devices remain unproven in efficacy in acute liver failure. age at time of exposure. Hepatitis B can be associated with ALF through a number of ........................................................................... scenarios (table 2). The commonest are de novo infection and spontaneous surges in viral repli- cation, while the incidence of the delta virus cute liver failure (ALF) is a complex infection seems to be decreasing rapidly. multisystemic illness that evolves after a Vaccination should reduce the incidence of Acatastrophic insult to the liver manifesting hepatitis A and B, while antiviral drugs should in the development of a coagulopathy and ameliorate replication of hepatitis B.
    [Show full text]
  • Management of Autoimmune Liver Diseases After Liver Transplantation
    Review Management of Autoimmune Liver Diseases after Liver Transplantation Romelia Barba Bernal 1,† , Esli Medina-Morales 1,† , Daniela Goyes 2 , Vilas Patwardhan 1 and Alan Bonder 1,* 1 Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; [email protected] (R.B.B.); [email protected] (E.M.-M.); [email protected] (V.P.) 2 Department of Medicine, Loyola Medicine—MacNeal Hospital, Berwyn, IL 60402, USA; [email protected] * Correspondence: [email protected]; Tel.: +1-617-632-1070 † These authors contributed equally to this project. Abstract: Autoimmune liver diseases are characterized by immune-mediated inflammation and even- tual destruction of the hepatocytes and the biliary epithelial cells. They can progress to irreversible liver damage requiring liver transplantation. The post-liver transplant goals of treatment include improving the recipient’s survival, preventing liver graft-failure, and decreasing the recurrence of the disease. The keystone in post-liver transplant management for autoimmune liver diseases relies on identifying which would be the most appropriate immunosuppressive maintenance therapy. The combination of a steroid and a calcineurin inhibitor is the current immunosuppressive regimen of choice for autoimmune hepatitis. A gradual withdrawal of glucocorticoids is also recommended. Citation: Barba Bernal, R.; On the other hand, ursodeoxycholic acid should be initiated soon after liver transplant to prevent Medina-Morales, E.; Goyes, D.; recurrence and improve graft and patient survival in primary biliary cholangitis recipients. Unlike the Patwardhan, V.; Bonder, A. Management of Autoimmune Liver previously mentioned autoimmune diseases, there are not immunosuppressive or disease-modifying Diseases after Liver Transplantation.
    [Show full text]
  • Spontaneous Bacterial Peritonitis: Recent Guidelines and Beyond R Wiest,1 a Krag,2 a Gerbes3
    Downloaded from gut.bmj.com on May 31, 2012 - Published by group.bmj.com Recent advances in clinical practice Spontaneous bacterial peritonitis: recent guidelines and beyond R Wiest,1 A Krag,2 A Gerbes3 1Department for visceral surgery INTRODUCTION prognosis in various cohorts of patients with SBP and medicine, University Spontaneous bacterial peritonitis (SBP) is the most are summarised in figure 1 and include age,16 20 Hospital Bern, Switzerland 18 20 23 16 18 2 frequent and life-threatening infection in patients Child score, intensive care, nosocomial Department of 18 24 25 Gastroenterology, Hvidovre with liver cirrhosis requiring prompt recognition origin, hepatic encephalopathy, elevated 26 University Hospital, and treatment. It is defined by the presence of >250 serum creatinine and bilirubin, lack of infection Copenhagen, Denmark polymorphonuclear cells (PMN)/mm3 in ascites in resolution/need to escalate treatment and culture 3 e Klinikum of the University of the absence of an intra-abdominal source of infec- positivity27 29 as well as the presence of bacter- Munich, Munich, Germany tion or malignancy. In this review we discuss the aemia30 and CARD15/NOD2 variants as a genetic fl 31 Correspondence to current opinions re ected by recent guidelines risk factor. It is important to stress in this context Professor Dr Reiner Wiest, (American Association for the Study of Liver that the only factors that are modifiable in this Department for visceral surgery Diseases, European Association for the Study of the scenario are timely diagnosis and effective first-line and medicine, University Liver, Deutsche Gesellschaft für Verdauungs- und treatment. Hospital Bern, 3010 Bern, 1e4 Switzerland; Stoffwechselkrankheiten), with particular focus [email protected] on controversial issues as well as open questions Bacterial translocation (BT) and pathophysiology that need to be addressed in the future.
    [Show full text]
  • Acute Liver Failure
    Acute Liver Failure ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• When liver failure occurs in a previou ly healthy individual, it onset is often o rapid that it take experienced physicians by WILLIAM M. LEE surprise. Terms such a hyperacute or fulminant hepatic necrosis have been u ed to emphasize the rapidity and everity of the JULIE POLSON condition. The onset of acute liver failure is heralded by an altered mental state, often with agitation and confusion that may proceed to coma, and by evidence of coagulopathy [1 - 4]. The diagno is of acute liver failure require that these symptom develop in a patient without preexisting chronic liver disease. Although not all observers agree on precise definitions, it is generally accepted that onset of liver-related illness (usually, but not always, accompanied by jaundice) les than 8 weeks before patient presentation with altered mentation and coagulopathy fits the designation of acute liver failure. Development of these signs within a week of onset of liver disease and as much as 6 months from the first sign of illness is sometimes referred to as hyperacute and ubacute liver failure, respectively. An immediate challenge in managing sud1 patients is deter­ mination of the cause of acute liver failure in each case. Wherea certain factors, such a extent of encephalopathy and development of various complications, have an impact on outcome, the underlying etiology best determines the likeli­ hood of spontaneous survival or the need for urgent liver trans­ plantation [3,4]. The primary cause of acute liver failure vary in prevalence in different region of the world, and include drug toxicity and viral infections; there i also a large category of cases in which the pecific etiology cannot be determined.
    [Show full text]
  • Indication and Assessment for Liver Transplantation
    CME Liver disease 14 Rossle M, Ochs A, Gulberg V, Siegerstetter V, et al. A comparison of paracentesis and Indication and assessment for transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J liver transplantation Med 2000;342:1701–7. 15 Lake JR. The role of transjugular shunting in patients with ascites. N Engl J Med 2000; 342:1745–7. Paul B Southern MB ChB MRCP , used. The Child-Pugh classification 2 Transplant Fellow (Table1) allows objective assessment of a Mervyn H Davies MD FRCP, patient’s functional liver status and in the Lead Clinician in Hepatology USA forms the basis for the criteria Department of Medical Hepatology, required to list patients. Those with St James’s University Hospital, Leeds Childs C grade have a 58%, 21% and 0% one-year, five-year and 10-year survival, Clin Med JRCPL 2002;2:313–6 respectively. Subjective measures of liver disease may be more difficult to assess. Tools are Liver transplantation provides effective available to document quality of life 3, therapy for most forms of acute and and a full psychosocial assessment chronic liver failure – one-year survival should be carried out. rates exceed 90% 1 – and the indications continue to expand. In general terms, the Cholestatic liver disease indications for liver transplantation are objective evidence of liver failure and Primary biliary cirrhosis subjective criteria such as poor quality of Primary biliary cirrhosis (PBC) is a life due to liver disease and occasionally declining indication for liver transplan- rare metabolic defects. tation, but still accounted for 7.8% of liver transplants in Europe in 1998– Chronic liver disease 20001.
    [Show full text]
  • Definition and Treatment of Liver Failure
    102 Korea Digestive Disease Week Definition and Treatment of Liver Failure Seung Kak Shin, M.D. Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea INTRODUCTION the definition of the European Liver Association (EASL) Chronic Liver Liver failure can be divided into acute liver failure (ALF) due to acute Failure Consortium (CLIF-C) have been most widely used, although liver injury without previous history of liver disease or liver cirrhosis, they have not yet reached a fully uniform definition throughout the and chronic liver failure (also called end stage liver disease) resulting world. In European multicenter study (CANONIC study), bacterial in gradual progression of chronic liver disease. Recently, the new infection and active alcoholism, which are important mechanisms of concept of acute on chronic liver failure (ACLF) has emerged. systemic inflammation, were the most frequent precipitating events. (7) In Korean multicenter study (KACLif study), bacterial infection and gastrointestinal bleeding were more frequent in ACLF patients DEFINITION OF LIVER FAILURE according to the EASL-CLIF definition, while active alcoholism and use 1. Definition of ALF of toxic material were more frequent in ACLF patients according to the The most widely accepted definition of ALF includes evidence of AARC definition.(8) coagulation abnormality, usually an INR ≥ 1.5, and any degree of mental alteration (hepatic encephalopathy, HEP) in a patient without TREATMENT OF LIVER FAILURE preexisting cirrhosis and with an illness of <26 weeks’ duration.(1- 2) In the absence of any alteration of consciousness, the patient who 1. Treatment of ALF develop coagulopathy was defined as acute liver injury (ALI), not liver In patients with severe acute liver injury, screen intensively for failure.
    [Show full text]
  • Primary Biliary Cholangitis: 2018 Practice Guidance from the American Association for the Study of Liver Diseases 1 2 3 4 5 Keith D
    | PRACTICE GUIDANCE HEPATOLOGY, VOL. 0, NO. 0, 2018 Primary Biliary Cholangitis: 2018 Practice Guidance from the American Association for the Study of Liver Diseases 1 2 3 4 5 Keith D. Lindor, Christopher L. Bowlus, James Boyer, Cynthia Levy, and Marlyn Mayo Intended for use by health care providers, this guid- Preamble ance identifies preferred approaches to the diagnostic This American Association for the Study of and therapeutic aspects of care for patients with PBC. Liver Diseases (AASLD) 2018 Practice Guidance As with clinical practice guidelines, it provides gen- on Primary Biliary Cholangitis (PBC) is an update eral guidance to optimize the care of the majority of of the PBC guidelines published in 2009. The 2018 patients and should not replace clinical judgment for updated guidance on PBC includes updates on etiol- a unique patient. ogy and diagnosis, role of imaging, clinical manifesta- The major changes from the last guideline to this tions, and treatment of PBC since 2009. The AASLD guidance include information about obeticholic acid 2018 PBC Guidance provides a data-supported (OCA) and the adaptation of the guidance format. approach to screening, diagnosis, and clinical man- agement of patients with PBC. It differs from more recent AASLD practice guidelines, which are sup- Etiology of Primary Biliary ported by systematic reviews and a multidisciplinary panel of experts that rates the quality (level) of the Cholangitis evidence and the strength of each recommendation Primary Biliary Cholangitis (PBC) is considered using the Grading of Recommendations Assessment, an autoimmune disease because of its hallmark sero- Development, and Evaluation system. In contrast, this logic signature, antimitochondrial antibody (AMA), (1-4) guidance was developed by consensus of an expert and specific bile duct pathology.
    [Show full text]
  • Arterial Ammonia Levels As a Predictor of Mortality in Acute Liver Failure
    RESEARCH HIGHLIGHTS www.nature.com/clinicalpractice/gasthep linked to adverse events such as nephrotoxicity. The median arterial ammonia concentration Conventional ultrasound is of limited use in at admission was 128.6 μmol/l. The median the diagnosis of acute pancreatitis, primarily time from admission to death (42/80 patients) because it cannot detect pancreatic necrosis was 4 days. Median arterial ammonia con- effectively. Use of echo enhancement improves centration was significantly higher in patients ultrasound imaging of organ perfusion; echo- who died (174.7 μmol/l) than in survivors enhanced ultrasound (EEUS) is less costly than (105.0 μmol/l, P <0.001). By regression analy- CT, has fewer side effects, and can be used to sis, an arterial ammonia level of ≥124 μmol/l diagnose acute pancreatitis. In this prospective was found to have a sensitivity of 78.6% and study, Rickes et al. compared the diagnostic per- specificity of 76.3% as a predictor of death formance of EEUS and CT and the relationship (P <0.001). Ammonia levels above this value between EEUS data and clinical parameters. had an odds ratio of 10.9 as a predictor of An experienced examiner who was blinded death (95% CI 5.9–284.0). Other factors found to prior laboratory and imaging findings per- to be highly predictive of death were cerebral formed conventional ultrasound, EEUS and CT edema (odds ratio 12.6; 95% CI 1.5–108.5) scans of 31 patients (24 men) with acute pan- and blood pH of 7.4 or below (odds ratio 6.6; creatitis, aged 19–67 years (mean 39 years), 95% CI 0.8–57.5).
    [Show full text]
  • Acute Liver Failure 급성간부전
    KLTS Coordinator Session (K*) Acute Liver Failure Dong Jin Joo Department of Surgery, Yonsei University College of Medicine, Seoul, Korea 급성간부전 주 동 진 연세대학교 의과대학 외과학교실 Acute liver failure (ALF) is a rare disease but it could be life-threatening and devastating condition with up to 30- 50% mortality rate, which occurs mostly in patients who do not have preexisting liver disease. The incidence of ALF is around 10 cases per million persons per year in the developed countries. Some cases may be salvaged by vigorous medical treatment together with the liver’s capacity for regeneration, but orthotopic liver transplantation remains the definitive therapy for medically refractory ALF. Conventionally, fulminant hepatic failure is defined as a severe liver injury, potentially reversible in nature and with onset of hepatic encephalopathy within 8 weeks of the first symptoms in the absence of preexisting liver disease. But, the time gap between jaundice and hepatic encephalopathy differs according to the causes of liver failure. Globally, hepatitis A and E infections are related to acute liver failure, with rates of mortality of more than 50% reported from the developing countries. ALF can be caused by hepatitis B infection. Particularly in Korea, acute on chronic liver failure caused by hepatitis B is not uncommon and sometimes ALF can occur in patients with reactiva- tion of previously stable subclinical HBV infection without established chronic liver disease. Another important cause of ALF is drug-induced liver injury. Drug-induced liver injury is responsible for approximately 50% of cases of acute liver failure in the United States. Acetaminophen is the most common hepatotoxic drug that could induce ALF in western countries.
    [Show full text]
  • Acute Liver Failure
    Clinical Medicine 2020 Vol 20, No 5: 505–8 CME: HEPATOLOGY Acute liver failure Authors: Mohammed A Arshad,A Nicholas MurphyB and Mansoor N BangashC Acute liver failure is a rare syndrome and is primarily caused evidence-based guidelines on the management of acute liver by paracetamol toxicity in developed nations. Survival for failure.4 In this article, we briefly review what the generalist needs patients with acute liver failure has steadily improved over to know about ALF. the last few decades from approximately 20% to greater than 60%. This marked improvement in survival has been due to Classification ABSTRACT a combination of improvements in medical practice and the use of emergency liver transplantation in selected patients. The presentation of ALF varies according to aetiology, and Early recognition and timely initial management in the non- aetiologies vary in their relative frequency across the globe. specialist centre can significantly improve outcomes. Patients Consequently, several differing classification systems exist but should be simultaneously discussed with a transplant centre essentially all differentiate between rapidly progressive ALF and referred to critical care. Close liaison with transplant and other forms. This distinction holds prognostic significance. centres to ensure timely transfer in deteriorating patients is The UK tends to use the O’Grady classification. Patients present important. as either ‘hyperacute’, ‘acute’ or ‘subacute’ dependent upon the emergence of encephalopathy following the first detected symptoms, often jaundice (Fig 1).5 Hyperacute presentations Introduction frequently develop extrahepatic organ failure and carry a high risk of cerebral oedema and intracranial hypertension but, counter- Acute liver failure (ALF) is a rare syndrome with a UK incidence intuitively, carry the best prognosis with medical treatment alone.
    [Show full text]
  • Acute Liver Failure
    Acute Liver Failure A. W. HOLT Department of Critical Care Medicine, Flinders Medical Centre, Adelaide, SOUTH AUSTRALIA ABSTRACT Objective: To consider the classification and to present an approach to the diagnosis and management of complications associated with acute liver failure. Data sources: A review of studies reported from 1966 to 1998 and identified through a MEDLINE search on treatment of acute liver failure. Summary of review: Acute liver failure can be subdivided into hyperacute, (encephalopathy within 7 days of onset of jaundice) acute (8-28 days from jaundice to encephalopathy) and subacute (29 to 72 days from jaundice to encephalopathy) forms. Management of all forms involves largely supportive care until hepatocyte regeneration and recovery occurs (predominantly in the hyperacute group), or bridging supportive therapy until orthotopic liver transplantation can be performed. New therapies such as bioartificial liver support devices and ex-vivo liver perfusion offer exciting possibilities for this bridging therapy. While orthotopic liver transplantation remains the definitive treatment for many patients with acute liver failure, N- acetyl-cystine (150 mg/kg over 15 minutes followed by 12.5 mg/kg/hour) and PGE1 (10 – 40 µg/hour) are reported to have an additional role and are being used increasingly in the management of all forms of acute liver failure. Conclusions: Acute liver failure is the end stage of many acute viral and drug induced hepatic diseases. Management is largely supportive until hepatic repair or transplantation can be performed. Recently, additional hepatic protective, regenerative and supportive therapies have been successfully used. (Critical Care and Resuscitation 1999; 1: 25-38) Key words: Acute liver failure, hepato-renal syndrome, hepatic encephalopathy, cerebral oedema, liver assist device, orthotropic liver transplantation Classification King’s group, the French do not recognise the Two different classifications of acute liver failure ‘hyperacute’group.
    [Show full text]
  • Empiric Treatment of Suspected Infection in Pediatric Patients With
    Empiric Treatment of Suspected Infection in Pediatric Patients with End-Stage Liver Disease/Biliary Atresia Applies to pre-transplant pediatric patients with known liver disease primarily at risk for infection with enteric organisms Pediatric Hepatology service should be Initial Evaluation: Initial evaluation should determine consulted if not already aware of patient Obtain cultures before antibiotics when likelihood of ascending cholangitis, vs. possible spontaneous bacterial peritonitis (SBP), vs. other community- or hospital-onset Physical examination infectious source. See separate algorithm for Blood culture - all CVC lumens + peripheral neonatal and pediatric patients U/A + urine culture Ascending cholangitis should be with suspected infection at AST, ALT, total & direct bilirubin, GGT, suspected with fever and an increase in initial evaluation for alkaline phosphatase bilirubin from baseline acute liver failure If respiratory signs/symptoms: SBP should be suspected in a patient See separate algorithm for Endotracheal aspirate if intubated with ascites who has fever and suspected hospital-onset Chest X-ray abdominal pain/tenderness infection in patients with acute Consider respiratory virus testing liver failure or early If the patient is clinically stable and an post-transplantation If ascites: Paracentesis if able obvious focal source is identified on exam (e.g. acute otitis media, URI), not Avoid culturing long term biliary drains all of the recommended evaluation may be needed. Use clinical judgement. Continue evaluation for
    [Show full text]