Acute Liver Failure

Clinical Description

Acute liver failure (ALF) manifests with rapid deterioration in the synthetic and excretory liver functions with impaired coagulation (INR >1.5) and signs of encephalopathy in adults and pediatrics. ALF may lead to the following complications: Hypoglycemia, electrolyte abnormalities, acidosis, renal impairment, ascites, sepsis.

Acute Liver failure can be caused by the following:

• Infection (acute viral hepatitis, herpes simplex virus, CMV, HIV, TORCH)
• Autoimmune hepatitis
• Alcoholic hepatitis
• Drugs and Toxins (Paracetamol, ART, TB drugs especially isoniazid, NSAIDS, statins, antibiotics (amoxicillin, sulfonamides, tetracyclines), amanita mushroom)
• Metabolic diseases
• Pregnancy: fatty liver, HELLP syndrome

Signs and Symptoms

• Jaundice
• Fever
• Malaise
• Altered level of consciousness
• Right upper quadrant pain
• hepatomegaly
• Bleeding tendencies

Investigations

• Random blood glucose
• Liver function test
• Hepatitis serology
• Viral serology
• HIV test
• Urea, electrolytes and Creatinine
• Clotting profile
• Drug levels
• Ferritin
• Serum copper
• serum iron

Non-pharmacological

• Stop offending drugs or alcohol.
• Acute: ABCD approach
• Treat hypoglycemia according to protocol
• Restrict dietary protein.
• Monitor urine output.
• Counsel parents

Pharmacological

Coagulotherapy

Adults

• Vitamin K 10mg IV for 3 days, consider giving FFP 3 units if bleeding actively.

Paediatrics

• Vitamin K 5-10mg/kg IV daily (DO NOT GIVE IM)
• Fresh frozen plasma 10ml/kg IV
• Cryoprecipitate, platelets or factor VII concentrate

Cerebral oedema in acute liver failure

Adults

• Neuroprotective measures
• Mannitol 0.5-2g /kg IV over 1 hour (repeated every 6 to 8 hours for maximum 48 hours) Don’t repeat if no response.

Paediatrics

• Two thirds of maintenance fluids
• Neuroprotective measures
• Mannitol 0.5-2g /kg IV over 1 hour (repeated every 6 to 8 hours for maximum 48 hours) Don’t repeat if no response.

Hepatic Encephalopathy

Adults

• Give Lactulose 30mg po every 4hrs – aim for 2-4 bowel movements/day OR

Neomycin 1g every 6hrs for 7 days

In Pediatrics:

• Give oral Neomycin 1g/m2 4-6hourly or Kanamycin IV STAT dose
• Neonate <1-week 15mg/kg
• 1 week – 10 years 25mg/kg
• >10 years 20mg/kg
• Oral Lactulose 1ml/kg hourly until child has diarrhoea then 6 to 8 hourly.

Sepsis in liver failure

Adults

• Give Ceftriaxone 1g every day IV for 5 days

Hypoglycemia in liver failure

Adults

• 50mls 50% Dextrose IV push, maintenance with 10% Dextrose 1 litre/12 hours

Paediatrics

• Manage hypoglycemia according to protocol. Avoid sedatives