Indian National Association for the Study of Liver Consensus Statement on Acute Liver Failure (Part-2): Management of Acute Liver Failure

Abstract

Acute liver failure (ALF) is not an uncommon complication of a common disease such as acute hepatitis. Viral hepatitis followed by antituberculosis drug-induced hepatotoxicity are the commonest causes of ALF in India. Clinically, such patients present with appearance of jaundice, encephalopathy, and coagulopathy. Hepatic encephalopathy (HE) and cerebral edema are central and most important clinical event in the course of ALF, followed by superadded infections, and determine the outcome in these patients. The pathogenesis of encephalopathy and cerebral edema in ALF is unique and multifactorial. Ammonia plays a crucial role in the pathogenesis, and several therapies aim to correct this abnormality. The role of newer ammonia-lowering agents is still evolving. These patients are best managed at a tertiary care hospital with facility for liver transplantation (LT). Aggressive intensive medical management has been documented to salvage a substantial proportion of patients. In those with poor prognostic factors, LT is the only effective therapy that has been shown to improve survival. However, recognizing suitable patients with poor prognosis has remained a challenge. Close monitoring, early identification and treatment of complications, and couseling for transplant form the first-line approach to manage such patients. Recent research shows that use of dynamic prognostic models is better for selecting patients undergoing liver transplantation and timely transplant can save life of patients with ALF with poor prognostic factors.

Keywords: ACLF, Acute on Chronic liver Failure; AKI, Acute kidney injury; ALF, Acute Liver Failure; ALFED score; ALT, alanine transaminase; AST, aspartate transaminase; CNS, central nervous system; CT, Computerized tomography; HELLP, Hemolysis, elevated liver enzymes, and low platelets; ICH, Intracrainial hypertension; ICP, Intracrainial Pressure; ICU, Intensive care unit; INR, International normalised ratio; LAD, Liver assist device; LDLT, Living donor liver transplantation; LT, Liver transplantation; MAP, Mean arterial pressure; MELD, model for end-stage liver disease; MLD, Metabolic liver disease; NAC, N-acetyl cysteine; PALF, Pediatric ALF; WD, Wilson's Disease; acute liver failure; artificial liver support; liver transplantation; plasmapheresis.