Acute liver failure

Acute liver failure is a rare, life-threatening, potentially reversible condition defined by jaundice, coagulopathy, and hepatic encephalopathy.

Occurs in patients with no pre-existing liver disease and may result in severe liver impairment and rapid clinical deterioration.

The aetiology and the interval from onset of jaundice to the development of encephalopathy have a significant impact on prognosis.

Aetiology is established by history, serological assays, and exclusion of alternative causes, including acute presentations of chronic liver diseases.

Treatment involves intensive care unit monitoring, specific therapies based on aetiology, and management of known complications.

All patients should be considered for possible liver transplantation.

Prognostic models may be used to assess the probability of spontaneous recovery and are instrumental in selection of patients who should potentially undergo liver transplantation.

Acute liver failure (ALF) is a rare, life-threatening, potentially reversible condition with a rapid decline in hepatic function characterised by jaundice, coagulopathy (INR >1.5), and hepatic encephalopathy in patients with no evidence of prior liver disease.[1]Trey C, Davidson CS. The management of fulminant hepatic failure. Prog Liver Dis. 1970;3:282-98. http://www.ncbi.nlm.nih.gov/pubmed/4908702?tool=bestpractice.com [2]Gimson AE, O'Grady J, Ede RJ, et al. Late onset hepatic failure: clinical, serological and histological features. Hepatology. 1986 Mar-Apr;6(2):288-94. http://www.ncbi.nlm.nih.gov/pubmed/3082735?tool=bestpractice.com [3]Bernuau J, Rueff B, Benhamou JP. Fulminant and subfulminant liver failure: definitions and causes. Semin Liver Dis. 1986 May;6(2):97-106. http://www.ncbi.nlm.nih.gov/pubmed/3529410?tool=bestpractice.com [4]Shingina A, Mukhtar N, Wakim-Fleming J, et al. Acute liver failure guidelines. Am J Gastroenterol. 2023 Jul 1;118(7):1128-53. https://journals.lww.com/ajg/fulltext/2023/07000/acute_liver_failure_guidelines.14.aspx http://www.ncbi.nlm.nih.gov/pubmed/37377263?tool=bestpractice.com ​​

If these symptoms occur in a patient with pre-existing liver disease, the term acute-on-chronic liver failure is used, and is considered a separate diagnosis from ALF.[4]Shingina A, Mukhtar N, Wakim-Fleming J, et al. Acute liver failure guidelines. Am J Gastroenterol. 2023 Jul 1;118(7):1128-53. https://journals.lww.com/ajg/fulltext/2023/07000/acute_liver_failure_guidelines.14.aspx http://www.ncbi.nlm.nih.gov/pubmed/37377263?tool=bestpractice.com ​[5]Bajaj JS, O'Leary JG, Lai JC, et al. Acute-on-chronic liver failure clinical guidelines. Am J Gastroenterol. 2022 Feb 1;117(2):225-52. https://www.doi.org/10.14309/ajg.0000000000001595 http://www.ncbi.nlm.nih.gov/pubmed/35006099?tool=bestpractice.com

ALF may be classified as hyperacute, acute, or subacute, depending on the interval from the onset of jaundice to the development of encephalopathy.[3]Bernuau J, Rueff B, Benhamou JP. Fulminant and subfulminant liver failure: definitions and causes. Semin Liver Dis. 1986 May;6(2):97-106. http://www.ncbi.nlm.nih.gov/pubmed/3529410?tool=bestpractice.com ​[4]Shingina A, Mukhtar N, Wakim-Fleming J, et al. Acute liver failure guidelines. Am J Gastroenterol. 2023 Jul 1;118(7):1128-53. https://journals.lww.com/ajg/fulltext/2023/07000/acute_liver_failure_guidelines.14.aspx http://www.ncbi.nlm.nih.gov/pubmed/37377263?tool=bestpractice.com ​[6]O'Grady JG, Schalm SW, Williams R. Acute liver failure: redefining the syndromes. Lancet. 1993 Jul 31;342(8866):273-5. http://www.ncbi.nlm.nih.gov/pubmed/8101303?tool=bestpractice.com

The term acute liver failure is preferred over fulminant hepatic failure or acute hepatic necrosis, although these terms have been used historically to classify hepatic failure.[1]Trey C, Davidson CS. The management of fulminant hepatic failure. Prog Liver Dis. 1970;3:282-98. http://www.ncbi.nlm.nih.gov/pubmed/4908702?tool=bestpractice.com [2]Gimson AE, O'Grady J, Ede RJ, et al. Late onset hepatic failure: clinical, serological and histological features. Hepatology. 1986 Mar-Apr;6(2):288-94. http://www.ncbi.nlm.nih.gov/pubmed/3082735?tool=bestpractice.com [7]Lee WM, Squires RH Jr, Nyberg SL, et al. Acute liver failure: summary of a workshop. Hepatology. 2008 Apr;47(4):1401-15. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3381946 http://www.ncbi.nlm.nih.gov/pubmed/18318440?tool=bestpractice.com