20th April 2024

Acute Liver Failure

Background

Functions of the liver include synthesis of albumin, clotting factors and bile, metabolism of drugs and toxins and glucose regulation. Liver failure refers to the development of severe liver injury with encephalopathy and impaired synthetic function. The most common cause of acute liver failure in the UK is paracetamol overdose, but it can also be due to drug reactions, viral infection or ischaemia.

Presentation

Acute liver failure can be hyperacute (<7 days), acute (7-21 days) or subacute (3-26 weeks). Patients are unwell with signs of hepatic encephalopathy and may develop jaundice, tachycardia and reduced blood pressure, mimicking sepsis. It can occur in isolation or on a background of underlying chronic liver disease (known as acute-on-chronic liver failure), which may be mistaken for acute liver failure if it is a first presentation.

Diagnosis

Acute liver failure is a clinical diagnosis based on the presence of hepatic encephalopathy in a patient with acute liver disease. Blood tests will show significantly elevated transaminases (ALT and AST) and bilirubin, prolonged prothrombin time (PT) and high INR (>1.5), and usually low platelet count and serum albumin. Hypoglycaemia is common and patients may develop metabolic acidosis. Paracetamol levels should be performed in patients with suspected overdose, as they can guide treatment. Signs of chronic liver disease (portal hypertension) are absent in acute liver failure.

Management

Acute liver failure can be life-threatening, and supportive management is key. Hepatotoxic drugs should be avoided and patients should receive IV fluid replacement, adequate nutrition (preferably enteral feeding) and vitamin K. Hepatic encephalopathy and renal failure should be monitored for and treated if present. N-acetylcysteine (NAC) is given for paracetamol-induced liver failure and should be considered in all causes of liver failure. A liver transplant may be required in severe cases.

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