Acute liver failure management: Catalan Society of Digestology Guideline

The Catalan Society of Digestology has released clinical guidelines for the management of acute liver failure (ALF).

The guideline, published in the journal Gastroenterología y Hepatología, contains recommendations on the definition, aetiology, initial management and treatment of complications in acute liver failure.

Definition

• ALF is defined as a syndrome, characterised by markers of hepatocellular failure (jaundice and INR > 1.5) accompanied by any grade of hepatic encephalopathy. (HE).


• Although they may have previous liver damage, patients with acute presentation of Wilson's disease, reactivation of hepatitis B virus (HBV) in a non-cirrhotic liver, acute Budd-Chiari syndrome or chronic autoimmune hepatitis are considered to be affected by ALF if they develop HE.


• The development of mild HE is sufficient to establish the diagnosis of ALF and to initiate the diagnostic and therapeutic protocol.


• The diagnosis of ALF in paediatric patients does not depend on the development of HE.


• It is crucial not to classify ALF with a subacute course as liver cirrhosis, as we would miss the opportunity of an emergency liver transplants (ELT) if it was necessary.

Aetiology

• The most common causes of ALF in our region are viral (especially HBV) and toxic/drug-induced. In recent years, there seems to have been an increase in the incidence of ALF due to paracetamol overdose, this being the main cause of ALF in Anglo-Saxon and Northern European countries.


• Thorough toxicological screening should be carried out in all cases and, if there is reasonable doubt, paracetamol levels should be checked. If this is not possible, N-acetyl-cysteine (NAC) should be started.


• Testing for possible viral infections as the cause is mandatory.


• Many cases of suspected autoimmune hepatitis require a liver biopsy for confirmation. This needs to be performed early as corticosteroid therapy could be effective. However, if after one week of treatment with corticosteroids there is no improvement, ELT should be considered because of the high risk of infection associated with the use of corticosteroids.


• If cancer spread to the liver is suspected (previous history of cancer or hepatomegaly), comprehensive imaging studies and/or liver biopsy should be performed.

Initial management

• Early referral of a patient with severe acute hepatitis to a centre with a liver transplant programme before the onset of HE means that assessment can begin for a potential ELT while giving the patient a greater chance of spontaneous survival or of making it to the ELT well enough to survive such complex surgery.


• Referral to a specialised centre is vital in cases of ALF with a subacute course, in view of the high incidence of associated complications, and in cases of extrahepatic involvement.


• Patients with ALF require strict monitoring which, at the very least, should include: clinical evaluation every 12 h; daily examination of physiological, analytical and metabolic parameters.


• Repeated assessment of the degree of HE must be carried out as routine.


• Kidney function should be monitored both analytically (serum creatinine) and clinically (hourly diuresis).


• Liver biopsy, by the transjugular route, is a useful but not essential tool. It is of greater utility in cases of cryptogenic ALF and when there is suspected invasion of cancer, liver cirrhosis or alcoholic hepatitis.


• Chest X-rays should be performed with some regularity, especially in intubated patients, in order to rule out pneumonia.


• Early administration (HE grade II or lower) of NAC is recommended in all patients regardless of suspected aetiology.


• In view of the patient's hypercatabolic state, we have to ensure adequate nutrition.


• The oral or enteral route is contraindicated in patients with HE grade II or higher.


• Patients in grade III-IV HE should have orotracheal intubation to preserve the airway and we must be alert for clinical signs of increased ICP.


• Hypoglycaemia is associated with a higher mortality rate and should, therefore, be avoided, while also avoiding hyperglycaemia.


• Hyponatraemia should be avoided. Maintaining serum sodium at 140–150 mEquiv./l is recommended.


• The routine use of fresh plasma and/or other clotting factors is contraindicated except in specific situations such as placement of intracranial sensors and the presence of active bleeding.


• Antibiotic prophylaxis does not increase survival in ALF, but it does reduce the incidence of infections.


• The administration of proton pump inhibitors should be considered on an individual basis, assessing the pros and cons.

Treatment of complications

• Patients with ALF require extremely delicate management of blood volume, avoiding both hypo- and hypervolaemia.


• In the case of persistent hypotension, vasoactive support should be initiated. Noradrenaline is the drug of choice.


• The use of hydrocortisone does not reduce the mortality rates associated with the condition, but it may reduce the need for vasoactive drugs.


• Strategies for ventilation are as standard (protective ventilation).


• Non-invasive techniques, such as transcranial Doppler, are not useful in the assessment of ICP.


• Invasive monitoring of ICP should be considered in patients at high risk of intracranial hypertension, i.e. in grade III-IV HE, intubated and ventilated patients, and with at least one of the following: young with hyperacute presentation; presence of seizures; three or more SIRS criteria; serum ammonia >150 μmol/l; serum sodium < 135 mEquiv./l; renal failure; the need for vasoactive support.


• Measures to prevent an increase in ICP should be applied in all cases. Hyperosmolar therapy (with mannitol or hypertonic saline) should be the first option in cases of intracranial hypertension.


• The occurrence of acidosis, metabolic (hyponatraemia, etc.) and haemodynamic (hypervolaemia) abnormalities in the context of renal failure require the early introduction of renal replacement therapy.


• Anticoagulation of the renal replacement therapy circuits is subject to debate and should be assessed on an individual basis.


• The continuous renal replacement techniques are those of choice.


• Serial cultures should be performed to monitor for the presence of infections or colonisation.


• Identification of clinical criteria for SIRS or sepsis or the progression of HE requires the prompt introduction of antibiotic therapy.


• Administration of antifungals should be considered in patients with prolonged stays in ICU.


• The assessment of the patient's prognosis must be carried out continuously in order to decide on the best therapeutic option at all stages.


• Factors of poor prognosis are severe hepatic involvement, extrahepatic involvement, and subacute presentation.


• ELT should be considered in patients who meet the criteria.


• The decision to perform an ELT must be taken by a multidisciplinary team who are experts in this procedure.


• Patients with ALF requiring an ELT should be put on a priority transplant.


• Artificial and bioartificial liver support systems should be used in the context of controlled clinical trials.


• High-volume plasma exchange has been associated with an increase in transplant-free survival in a randomised controlled trial.


• The efficacy of plasma exchange is higher when it is used early and in patients who do not subsequently require an ELT.

To read the full recommendations follow the link: https://doi.org/10.1016/j.gastre.2019.01.011