Materiały źródłowe

• #1 Acute liver failure in adults: Etiology, clinical manifestations, and diagnosis – UpToDate

  https://www.uptodate.com/contents/acute-liver-failure-in-adults-etiology-clinical-manifestations-and-diagnosis

  Acute liver failure is characterized by acute liver injury, hepatic encephalopathy (altered mental status), and an elevated prothrombin time/international normalized ratio (INR). […] This topic will review the etiology, clinical manifestations, and diagnosis of acute liver failure in adults. […] Acute liver failure refers to the development of severe acute liver injury with impaired synthetic function (INR of ≥1.5) and altered mental status in a patient without cirrhosis or preexisting liver disease. […] A commonly used cutoff to define acute liver failure is an illness duration of <26 weeks. [...] Diagnosing acute liver failure involves determining the cause of acute liver failure, which includes timing of the evaluation, history, physical examination, laboratory evaluation, imaging studies, and liver biopsy.

• #1 Acute liver failure in adults: Management and prognosis – UpToDate

  https://www.uptodate.com/contents/acute-liver-failure-in-adults-management-and-prognosis

  Acute liver failure refers to the development of severe acute liver injury with encephalopathy and impaired synthetic function (international normalized ratio [INR] of ≥1.5) in a patient without cirrhosis or pre-existing liver disease. […] Acute liver failure may also be diagnosed in patients with previously undiagnosed Wilson disease, vertically acquired hepatitis B virus, or autoimmune hepatitis, in whom underlying cirrhosis may be present, provided the disease has been recognized for <26 weeks. [...] The etiology, clinical manifestations, and diagnosis of patients with acute liver failure are discussed separately. [...] Timely recognition and management of patients with acute liver failure is crucial.

• #1 Acute Liver Failure (ALF) | UCSF Department of Surgery

  https://hpbsurgery.ucsf.edu/condition/acute-liver-failure-alf

  Acute liver failure (ALF) (also called fulminant hepatic failure) is a rare condition characterized by the abrupt onset of severe liver injury, manifest as a profound liver dysfunction as well as a confusional state called hepatic encephalopathy in individuals with no prior history of liver disease. The lack of prior liver disease is critical to the definition of ALF. […] Obtaining a detailed and accurate medical history from patients with ALF can be very challenging, if not impossible, due to the presence of an altered mental status. Thus, the clinician is usually forced to rely on family and friends of the ALF patient to obtain information about recent symptoms, medication use, risk factors for viral hepatitis (e.g., intravenous drug use, recent tattoos, recent travel, exposure to other ill individuals), and any significant past medical problems.

• #1 Acute Liver Failure – Hepatic and Biliary Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/approach-to-the-patient-with-liver-disease/acute-liver-failure

  Acute liver failure is caused most often by drugs and hepatitis viruses. Cardinal manifestations are jaundice, coagulopathy, and encephalopathy. Diagnosis is clinical. […] Acute liver failure should be suspected if patients without underlying chronic liver disease or cirrhosis have acute onset of jaundice and/or elevated transaminases that is accompanied by coagulopathy and mental status changes. […] Laboratory tests to confirm the presence and severity of liver failure include liver enzyme and bilirubin levels and INR. Acute liver failure is usually considered confirmed if sensorium is altered and INR is 1.5 in patients who have clinical and/or laboratory evidence of acute liver injury. […] To determine the cause of acute liver failure, clinicians should take a complete history of toxins ingested, including prescription and over-the-counter drugs, herbal products, and dietary supplements. Tests done routinely to determine the cause include viral hepatitis serologic tests and autoimmune markers. […] Various scores (for example, King’s College criteria or Acute Physiologic Assessment and Chronic Health Evaluation II [APACHE II] score) can predict prognosis in populations of patients but are not highly accurate for individual patients.

• #1 Acute liver failure – Symptoms, diagnosis and treatment | BMJ Best Practice US

  https://bestpractice.bmj.com/topics/en-us/1010

  Acute liver failure is a rare, life-threatening, potentially reversible condition defined by jaundice, coagulopathy, and hepatic encephalopathy. […] Occurs in patients with no preexisting liver disease and may result in severe liver impairment and rapid clinical deterioration. […] Etiology is established by history, serological assays, and exclusion of alternative causes, including acute presentations of chronic liver diseases. […] 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. […] Key diagnostic factors include hepatotoxic drugs, chronic alcohol misuse, pregnancy, jaundice, coagulopathy, and signs of hepatic encephalopathy. […] Other diagnostic factors include absence of history of chronic liver disease, abdominal pain, nausea, vomiting, malaise, signs of cerebral edema, right upper quadrant tenderness, hepatomegaly, absence of splenomegaly, absence of spider angiomata, absence of palmar erythema, absence of ascites, depression or suicidal ideation, Wilson disease, exposure to hepatotoxins, illicit drug use, and absence of malignancy.

• #1 Acute Liver Failure – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK482374/

  Acute liver failure is defined as severe acute liver injury for fewer than twenty-six weeks duration with encephalopathy and impaired synthetic function (INR of 1.5 or higher) in a patient without cirrhosis or preexisting liver disease. […] This activity reviews the etiology, evaluation, and management of acute liver failure. […] Outline how to evaluate a patient for acute liver failure. […] A high index of suspicion, early referral to a specialist liver transplantation center, and adequate supportive management remain the cornerstone for the management of ALF. […] An extensive workup for the etiology of ALF is recommended, as this guides directed therapy and helps determine the outcome. […] Prolonged INR greater than or equal to 1.5, often elevated bilirubin and aminotransferases, thrombocytopenia, with anemia, hypoglycemia, elevated ammonia and features of acute renal injury (with elevated serum creatinine), and dyselectrolytemia (hypokalemia, hypophosphatemia) is common.

• #1 Acute liver failure – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/1010

  Acute liver failure is a rare, life-threatening, potentially reversible condition defined by jaundice, coagulopathy, and hepatic encephalopathy. […] Aetiology is established by history, serological assays, and exclusion of alternative causes, including acute presentations of chronic liver diseases. […] 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. […] Key diagnostic factors include presence of risk factors, hepatotoxic drugs, chronic alcohol misuse, jaundice, coagulopathy, and signs of hepatic encephalopathy. […] 1st investigations to order include liver function tests, prothrombin time/INR, viscoelastic testing (VET), basic metabolic panel, FBC, blood type and screen, serum amylase and lipase, arterial blood gas, arterial blood lactate, paracetamol level, urine toxicology screen, viral hepatitis serologies, autoimmune hepatitis markers, pregnancy test, chest x-ray, and abdominal ultrasound with Doppler.

• #1 Acute Liver Failure Workup: Approach Considerations, Laboratory Studies, Blood Cultures

  https://emedicine.medscape.com/article/177354-workup

  The levels of the transaminases (aspartate aminotransferase [AST]/serum glutamic-oxaloacetic transaminase [SGOT], and alanine aminotransferase [ALT]/serum glutamic-pyruvic transaminase [SGPT]) are often elevated dramatically as a result of severe hepatocellular necrosis. […] By definition, the serum bilirubin level should be elevated in fulminant hepatic failure. It climbs as hepatic dysfunction worsens. […] The serum ammonia level may be elevated dramatically in patients with fulminant hepatic failure. […] Serum glucose levels may be dangerously low. […] Arterial blood gas evaluation is valuable for identifying acid-base imbalances. […] Serum creatinine levels may be elevated, signifying the development of hepatorenal syndrome or some other cause of acute renal failure. […] Patients with Wilson disease have low ceruloplasmin and total serum copper levels.

• #1 Acute liver failure – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/1010

  Investigations to consider include factor V level, viral hepatitis polymerase chain reaction (PCR) studies, serum ceruloplasmin, serum copper, 24-hour urinary copper excretion, slit-lamp ophthalmological examination, arterial ammonia, HIV test, urinalysis and urine sodium, surveillance cultures, Coombs test, biomarkers, liver biopsy, CT scan of head, CT/MR cholangiography, and transcranial Doppler.

• #1 Acute liver failure – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/acute-liver-failure/diagnosis-treatment/drc-20352868

  Tests and procedures used to diagnose acute liver failure include: […] Blood tests can show how well the liver works. A prothrombin time test measures how long it takes blood to clot. With acute liver failure, blood doesn’t clot as quickly as it should. […] A healthcare professional may recommend an ultrasound exam to look at the liver. Such testing may show liver damage and help find the cause of the liver problems. A health professional also may recommend abdominal computerized tomography (CT) scanning or magnetic resonance imaging (MRI) to look at the liver and blood vessels. These tests can look for certain causes of acute liver failure, such as Budd-Chiari syndrome or tumors. They may be used if a problem is suspected and ultrasound testing does not find the problem. […] A healthcare professional may recommend removing a small piece of liver tissue, called a liver biopsy. Doing so may help discover why the liver is failing.

• #1 Acute liver failure – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/acute-liver-failure/diagnosis-treatment/drc-20352868

  Since people with acute liver failure are at risk of bleeding during biopsy, a transjugular liver biopsy may be performed. This procedure involves making a tiny incision on the right side of the neck. A thin tube called a catheter is then inserted into a neck vein, through the heart and into a vein exiting the liver. A needle is then threaded through the catheter to retrieve a sample of liver tissue.

• #1 Update on Diagnosis and Management of Liver Failure. | RECAPEM

  https://recapem.com/update-on-diagnosis-and-management-of-liver-failure/

  Acute liver failure (ALF) is a life-threatening syndrome characterized by rapid deterioration of normal liver function following an acute insult in a patient with no previously known underlying chronic liver disease. Eventually, multiorgan failure may develop. […] ALF is defined as a severe liver injury in a patient who meets the following requirements: […] Impaired synthetic function (INR 1.5) with hepatic encephalopathy (HE) […] Patients who present without hepatic encephalopathy are considered to have acute liver injury (but not acute liver failure). […] HE occurring within 26 weeks of the first onset of symptoms of liver dysfunction (usually jaundice) *. […] The diagnosis of HE is clinical and requires the exclusion of other causes of neurological disturbance. Virtually no test can prove the presence of HE. […] Serum ammonia is neither sensitive nor specific for diagnosis of hepatic encephalopathy *. […] The primary entity in the differential diagnosis of acute liver failure is severe acute hepatitis. Patients with severe acute hepatitis have jaundice and coagulopathy but lack signs of hepatic encephalopathy. Differentiating severe acute hepatitis from acute liver failure (ALF) may be challenging in alcoholic hepatitis.

• #1 Acute liver failure differential diagnosis – wikidoc

  https://www.wikidoc.org/index.php/Acute_liver_failure_differential_diagnosis

  Acute liver failure must be differentiated from other diseases that cause signs and symptoms of jaundice, coagulopathy, and encephalopathy. The differentials include acute hepatitis, cholestatic jaundice, and hemolytic jaundice. […] Acute liver failure must be differentiated from other diseases that cause signs and symptoms of jaundice, coagulopathy, and encephalopathy. […] Acute hepatitis would not be considered acute liver failure unless hepatic encephalopathy is present. […] The absence of hepatic encephalopathy and coagulopathy will differentiate it from acute liver failure. […] Liver dysfunction may not be present. So, coagulopathy and hepatic encephalopathy would not be there.

• #1 Differential diagnosis of acute liver failure in India | Annals of Hepatology

  https://www.elsevier.es/en-revista-annals-hepatology-16-articulo-differential-diagnosis-acute-liver-failure-S1665268119319982

  Background: Acute liver failure (ALF) is a condition with rapid deterioration of liver function resulting in hepatic encephalopathy and/or coagulopathy in patients with previously normal liver. […] In developing countries, ALF-mimicking infections should be looked for in differential diagnosis of ALF. Early identification and treatment of these infections is important in reducing mortality. […] In tropical countries like India, where these infections are common; differentiation of ALF due to infectious diseases other than A-E hepatitis viruses (ALF-ID) from ALF due to acute viral A-E hepatitis (ALF-AVH) becomes crucial to provide specific therapy for ALF-ID in addition to supportive treatment for ALF. This study was planned to recognize features that can alert clinicians to suspect these infections in a patient with ALF and differentiate ALF-ID from ALF-AVH.

• #1 Differential diagnosis of acute liver failure in India | Annals of Hepatology

  https://www.elsevier.es/en-revista-annals-hepatology-16-articulo-differential-diagnosis-acute-liver-failure-S1665268119319982

  In a patient presenting with jaundice and encephalopathy (altered mentation) and/or coagulopathy (deranged coagulation parameters with/without systemic bleeding), primary diagnostic consideration is ALF-AVH, which is the commonest form of ALF in India. But, as seen in our study, presence of high grade fever, splenomegaly, mild ALT and AST elevation should make a clinician suspicious about presence of ID other than AVH. […] High index of suspicion and awareness are required to identify various common infections causing symptom complex similar to ALF. This help in identifying a patient with ALF who may have low mortality if specific treatment for such infection is given in time.

• #1 Acute Liver Failure – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK482374/

  The management of ALF consists of supportive care, prevention, and management of complications, specific treatment when the exact etiology is known, and determination of prognosis and the need for liver support including possible liver transplantation. […] The etiology of ALF and the hospital prognosis could help physicians ascertain whether a particular patient is likely to improve or not, and hence need a liver transplant. […] The treatment of ALF depends on the cause but at the same time, all patients need aggressive hydration. […] The outlook for patients with ALF depends on the cause, extent of liver damage, comorbidity, response to treatment, the age of the patient, and the number of organs involved.

• #1 Acute Liver Failure: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/177354-overview

  Laboratory testing […] Other studies may include the following: […] Imaging studies […] The most important aspect of treatment for acute liver failure is to provide good intensive care support, including the protection of the airways. […] The most important step in the assessment of patients with acute liver failure is to identify the cause, as certain causes demand immediate and specific treatment (see Workup). […] The outcome of acute liver failure is related to the etiology, the degree of encephalopathy, and related complications (see Prognosis). […] The risk of mortality increases with the development of any complications, which include cerebral edema, renal failure, adult respiratory distress syndrome (ARDS), coagulopathy, and infection.

• #1 A guide to managing acute liver failure | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/83/6/453

  Different criteria have been used to identify patients with poor prognosis who may eventually need to undergo liver transplant. […] The Kings College criteria system is the most commonly used for prognosis. Its main drawback is that it is applicable only in patients with encephalopathy, and when patients reach this stage, their condition often deteriorates rapidly, and they die while awaiting liver transplant. […] The Model for End-Stage Liver Disease (MELD) score is an alternative to the Kings College criteria. A high MELD score on admission signifies advanced disease, and patients with a high MELD score tend to have a worse prognosis than those with a low score. […] In addition to helping establish the cause of acute liver failure, liver biopsy can also be used as a prognostic tool. Hepatocellular necrosis greater than 70% on the biopsy predicts death with a specificity of 90% and a sensitivity of 56%.

• #1

  https://journals.lww.com/ccmjournal/fulltext/2024/10000/quality_evaluation_of_guidelines_for_the_diagnosis.12.aspx

  This study aimed to systematically assess the methodological quality and key recommendations of the guidelines for the diagnosis and treatment of liver failure (LF), furnishing constructive insights for guideline developers and equipping clinicians with evidence-based information to facilitate informed decision-making. […] Of the 14 guidelines, only the guidelines established by the Society of Critical Care Medicine and the American College of Gastroenterology (2023) achieved an aggregate quality score exceeding 60%, thereby meriting clinical recommendations. […] There are high differences in methodological quality and recommendations among LF guidelines. Improving these existing problems and controversies will benefit existing clinical practice and will be an effective way for developers to upgrade the guidelines.

• #1 A Comprehensive Review of the Diagnosis and Management of Acute Liver Failure

  https://www.mdpi.com/2077-0383/12/23/7451

  The management of specific etiologies of ALF is shown in Table 3. Empiric therapy is often started while awaiting workup for ALF if a patient’s history provides a particular etiology, in particular for acetaminophen toxicity. N-acetylcysteine (NAC) treatment improves outcomes in patients with acetaminophen-associated ALF; however, the quality of evidence for the optimal route of administration and dosing is poor. […] Early referral to a tertiary LT center should not be delayed while waiting for diagnostic workup and imaging test results. Decreasing levels of transaminases, increasing bilirubin, and INR are poor prognostic signs and these patients must immediately be transferred to an LT center with an ICU. Even patients who may not be LT candidates should be transferred to an experienced LT center to increase their chances of survival, and should be admitted to a specialized critical care unit, as management in the ICU decreases the mortality from 80% to 30%, especially in patients with grade II HE or higher.

• #1 Acute Liver Failure – Symptoms and Causes – UC Health

  https://www.uchealth.com/en/conditions/acute-liver-failure

  Acute liver failure is a serious condition that requires immediate medical attention. […] How is acute liver failure diagnosed? […] Your healthcare provider will probably do an evaluation to find out if you have a history of drug use, exposure to toxins, and to check for signs of hepatitis. […] Your healthcare provider will also test your mental alertness. He or she may also do blood tests. These tests will check your liver enzymes, bilirubin levels, and prothrombin time. […] Acute liver failure can happen in as little as 48 hours. It’s important to seek medical treatment at the first signs of trouble. […] Acute liver failure is a serious condition that requires immediate medical attention.

• #1 Update on Diagnosis and Management of Liver Failure. | RECAPEM

  https://recapem.com/update-on-diagnosis-and-management-of-liver-failure/

  The general management of a patient with ALF includes ensuring the patient is cared for in the proper setting, monitoring for worsening liver failure, and preventing further liver damage *. […] Serial laboratory tests are used to follow the course of a patients liver failure and to monitor for complications. […] The coagulopathies in liver failure are complex. Most procoagulants (clotting factors) and endogenous anticoagulants are synthesized in the liver. In advanced liver diseases, levels of all these proteins are reduced to a similar extent. This leads to rebalanced hemostasis wherein the clotting tendency is close to normal (more on this here).

• #1 Acute liver failure: Management update and prognosis | Revista de Gastroenterología de México

  https://www.revistagastroenterologiamexico.org/en-acute-liver-failure-management-update-articulo-S2255534X24000628

  The mortality rate is 25 to 30% and the main causes of death are sepsis and cerebral edema. […] The definition of ALF varies worldwide, but in the United States and Europe, the most accepted definition is that of a disease lasting less than 26 weeks. […] The main scales for determining disease severity are the Kings College Hospital criteria (KCC) and the Clichy-Villejuif criteria, among others. […] ALF that does not respond to supportive treatment is a clear indication for liver transplantation. […] The transplantation decision should be made in a time lapse not over 3 days, through the evaluation of a multidisciplinary team, with the intention of preventing the clinical deterioration that would contraindicate a liver transplant.

• #1 Acute Liver Failure: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/177354-overview

  Acute liver failure is an uncommon condition in which rapid deterioration of liver function results in coagulopathy, usually with an international normalized ratio (INR) of greater than 1.5, and alteration in the mental status (encephalopathy) of a previously healthy individual. Acute liver failure often affects young people and carries a very high mortality. […] The most important step in the assessment of patients with acute liver failure is to identify the cause, because certain conditions necessitate immediate and specific treatment and affect prognosis. All patients with clinical or laboratory evidence of moderate or severe acute hepatitis should have immediate measurement of prothrombin time (PT) and careful evaluation of the mental status. The presence of PT prolongation or mental status changes is grounds for hospital admission.

• #1 Acute Liver Failure: Symptoms, Causes, Diagnosis, Treatment

  https://www.healthline.com/health/acute-liver-failure

  Acute liver failure can develop rapidly in people with no pre-existing liver disease and requires immediate emergency medical attention. […] Doctors can use the following to help diagnose acute liver failure: a physical exam, review of your personal and family medical history, list of your symptoms and whether you’re taking any drugs or medications, blood tests to look for elevated liver enzymes like alanine and aspartate aminotransferase, which may reach 10 to 100 times the upper limit of normal, abdominal imaging with computed tomography (CT) scans, magnetic resonance imaging (MRI), ultrasound, brain MRI, liver biopsy. […] Acute liver failure tends to have a very poor outlook, although the survival rate has improved with the emergence of emergency liver transplants. The cause of death is often multi-organ failure or swelling in the brain. […] The survival rate for people who don’t receive a liver transplant ranges from about 10% to 40%. People who need a liver transplant now have an expected 1-year survival greater than 65%.

• #2 Acute Liver Failure – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK482374/

  Acute liver failure is defined as severe acute liver injury for fewer than twenty-six weeks duration with encephalopathy and impaired synthetic function (INR of 1.5 or higher) in a patient without cirrhosis or preexisting liver disease. […] This activity reviews the etiology, evaluation, and management of acute liver failure. […] Outline how to evaluate a patient for acute liver failure. […] A high index of suspicion, early referral to a specialist liver transplantation center, and adequate supportive management remain the cornerstone for the management of ALF. […] An extensive workup for the etiology of ALF is recommended, as this guides directed therapy and helps determine the outcome. […] Prolonged INR greater than or equal to 1.5, often elevated bilirubin and aminotransferases, thrombocytopenia, with anemia, hypoglycemia, elevated ammonia and features of acute renal injury (with elevated serum creatinine), and dyselectrolytemia (hypokalemia, hypophosphatemia) is common.

• #2 A Comprehensive Review of the Diagnosis and Management of Acute Liver Failure

  https://www.mdpi.com/2077-0383/12/23/7451

  Acute liver failure (ALF) is a rare and specific form of severe hepatic dysfunction characterized by coagulopathy and hepatic encephalopathy in a patient with no known liver disease. ALF carries a high morbidity and mortality. Careful attention should be given to hemodynamics and metabolic parameters along with the active surveillance of infections. Timely transfer and supportive management are important in an intensive care unit in a liver transplant center. Identifying patients who will and will not improve with medical management and may need emergent liver transplantation is critical. In this review, we provide a comprehensive update on the etiology, diagnosis, and management of ALF. […] Acute liver failure (ALF) refers to the development of severe hepatic dysfunction characterized by an international normalized ratio (INR) of ≥1.5 and altered mental status due to hepatic encephalopathy (HE) in a patient with no known liver disease. ALF is also referred to as fulminant hepatitis, acute hepatic necrosis, and fulminant hepatic necrosis. ALF is defined when the interval between the onset of jaundice and the development of HE is <26 weeks per the American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology guidelines.

• #2 Acute liver failure in adults: Management and prognosis – UpToDate

  https://www.uptodate.com/contents/acute-liver-failure-in-adults-management-and-prognosis

  Acute liver failure refers to the development of severe acute liver injury with encephalopathy and impaired synthetic function (international normalized ratio [INR] of ≥1.5) in a patient without cirrhosis or pre-existing liver disease. […] Acute liver failure may also be diagnosed in patients with previously undiagnosed Wilson disease, vertically acquired hepatitis B virus, or autoimmune hepatitis, in whom underlying cirrhosis may be present, provided the disease has been recognized for <26 weeks. [...] The etiology, clinical manifestations, and diagnosis of patients with acute liver failure are discussed separately. [...] Timely recognition and management of patients with acute liver failure is crucial.

• #2 Acute Liver Failure Workup: Approach Considerations, Laboratory Studies, Blood Cultures

  https://emedicine.medscape.com/article/177354-workup

  The most important step in patients with acute liver failure is to identify the cause. Prognosis in acute liver failure is dependent on the etiology. Acute liver failure from certain causes demands immediate and specific treatment. It is also critical to identify those patients who will be candidates for liver transplantation. […] All patients with clinical or laboratory evidence of moderate or severe acute hepatitis should have immediate measurement of prothrombin time (PT) and careful evaluation of the mental status. Prolongation of the PT, an international normalized ratio (INR) above 1.5, or alteration in mental sensorium is grounds for hospital admission or transfer to a specialized unit. […] A complete blood cell (CBC) count in patients with liver failure may reveal thrombocytopenia.

• #2 Acute Liver Failure | Cedars-Sinai

  https://www.cedars-sinai.org/health-library/diseases-and-conditions/a/acute-liver-failure.html

  How is acute liver failure diagnosed? Liver failure is a serious condition. It requires medical care right away. Your healthcare provider will ask about your past health, your use of medicines, illegal drugs, and unregulated natural supplements, and any possible exposure to toxins. You will also need a physical exam. Your healthcare provider may check for signs of hepatitis, such as jaundice, fatigue, and abdominal pain. […] You may also need: Tests for mental alertness, Blood tests. These check your liver enzymes and bilirubin levels. They also measure your blood’s ability to thicken (coagulate). This is called prothrombin time. […] Imaging tests. You may have a CT scan or MRI. These check your liver. […] Acute liver failure is a serious condition. It requires medical care right away.

• #2 Acute Liver Failure – Hepatic and Biliary Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/approach-to-the-patient-with-liver-disease/acute-liver-failure

  Acute liver failure is caused most often by drugs and hepatitis viruses. Cardinal manifestations are jaundice, coagulopathy, and encephalopathy. Diagnosis is clinical. […] Acute liver failure should be suspected if patients without underlying chronic liver disease or cirrhosis have acute onset of jaundice and/or elevated transaminases that is accompanied by coagulopathy and mental status changes. […] Laboratory tests to confirm the presence and severity of liver failure include liver enzyme and bilirubin levels and INR. Acute liver failure is usually considered confirmed if sensorium is altered and INR is 1.5 in patients who have clinical and/or laboratory evidence of acute liver injury. […] To determine the cause of acute liver failure, clinicians should take a complete history of toxins ingested, including prescription and over-the-counter drugs, herbal products, and dietary supplements. Tests done routinely to determine the cause include viral hepatitis serologic tests and autoimmune markers. […] Various scores (for example, King’s College criteria or Acute Physiologic Assessment and Chronic Health Evaluation II [APACHE II] score) can predict prognosis in populations of patients but are not highly accurate for individual patients.

• #2 Acute Liver Failure Workup: Approach Considerations, Laboratory Studies, Blood Cultures

  https://emedicine.medscape.com/article/177354-workup

  Consider electroencephalography in the evaluation of a patient with encephalopathy if seizures must be excluded. […] Drug-induced liver injury is a diagnosis of exclusion; a thorough history-taking and workup should be performed to rule out other possible etiologies. […] Liver biopsy should be considered to help confirm the presence of drug-induced liver injury, if autoimmune hepatitis may be associated with the condition, and when immunosuppressive agents are being considered. […] The widely used Roussel Uclaf Causality Assessment Method (RUCAM) scale may underestimate the risk of liver injury associated with herbal and dietary supplements. […] The PT and/or the international normalized ratio (INR) are used to determine the presence and severity of coagulopathy. These are sensitive markers of hepatic synthetic failure and are usually abnormal in the setting of fulminant hepatic failure.

• #2 Acute Liver Failure – LiverTox – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK548171/

  Last Update: December 11, 2019. […] Drug induced acute liver failure is defined by the appearance of signs or symptoms of hepatic failure and encephalopathy during the course of acute drug induced liver injury in a patient without previous or underlying chronic liver disease. […] The diagnosis of acute liver failure requires the finding of liver test abnormalities indicative of acute liver injury, accompanied by signs or symptoms of hepatic encephalopathy in a patient with no known previous liver injury. […] Typical features of acute liver failure include: Acute elevations in serum enzyme elevations with serum aminotransferase levels greater than 10 times the upper limit of the normal range, early in the course of illness. […] Other causes of acute liver failure that need to be excluded include acute hepatitis A, B, C, D and E, reactivation of hepatitis B, Wilson’s disease, ischemic hepatitis and tumor replacement of the liver.

• #2 Acute Liver Failure Workup: Approach Considerations, Laboratory Studies, Blood Cultures

  https://emedicine.medscape.com/article/177354-workup

  Antinuclear antibody (ANA), anti-smooth muscle antibody (ASMA), and immunoglobulin levels are important markers for the diagnosis of autoimmune hepatitis. […] In patients with liver failure from acetaminophen toxicity, the acetaminophen level may have decreased by the time a patient presents with fulminant hepatic failure. […] Consider a drug screen in a patient who is an intravenous drug abuser.

• #2 GGC Medicines – Management of Acute Liver Failure

  https://handbook.ggcmedicines.org.uk/guidelines/gastrointestinal-system/management-of-acute-liver-failure/

  Encephalopathy developing in a person with acute hepatic dysfunction within 8 weeks of the onset of jaundice. […] Acute liver failure strictly refers to those patients without such a history, and is much rarer. […] The guidelines, Acute Liver Failure and Management of Decompensated Liver Disease, are intended to help with both the acute case and with the deterioration of chronic cases. […] Immediate: FBC, coagulation screen, blood glucose, UEs, paracetamol levels, blood and urine cultures. […] Urgent (within 24 hours): LFTs, hepatitis serology (IgM anti-HAV, HBsAg, IgM anti-HBc and anti-HCV). […] Seek senior help early. ITU admission will be required for all grades of encephalopathy in the acute patient. […] In patients who have taken an overdose, early psychiatry review is paramount if there is any suggestion of liver failure, even out of hours, prior to the onset of encephalopathy; a major untreatable psychiatric diagnosis is a contraindication to liver transplantation (an acute depressive episode is not).

• #2 Acute liver failure – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/1010

  Acute liver failure is a rare, life-threatening, potentially reversible condition defined by jaundice, coagulopathy, and hepatic encephalopathy. […] Aetiology is established by history, serological assays, and exclusion of alternative causes, including acute presentations of chronic liver diseases. […] 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. […] Key diagnostic factors include presence of risk factors, hepatotoxic drugs, chronic alcohol misuse, jaundice, coagulopathy, and signs of hepatic encephalopathy. […] 1st investigations to order include liver function tests, prothrombin time/INR, viscoelastic testing (VET), basic metabolic panel, FBC, blood type and screen, serum amylase and lipase, arterial blood gas, arterial blood lactate, paracetamol level, urine toxicology screen, viral hepatitis serologies, autoimmune hepatitis markers, pregnancy test, chest x-ray, and abdominal ultrasound with Doppler.

• #2 Acute liver failure – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/1010

  Investigations to consider include factor V level, viral hepatitis polymerase chain reaction (PCR) studies, serum ceruloplasmin, serum copper, 24-hour urinary copper excretion, slit-lamp ophthalmological examination, arterial ammonia, HIV test, urinalysis and urine sodium, surveillance cultures, Coombs test, biomarkers, liver biopsy, CT scan of head, CT/MR cholangiography, and transcranial Doppler.

• #2 Diagnosis and management of acute liver failure – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-acute-liver-failure/

  4. In pregnant women presenting with ALF, AGA suggests testing for hepatitis E. […] 5. In patients presenting with ALF, AGA suggests using the Model for End-Stage Liver Disease (MELD) score rather than the Kings College Criteria (KCC) as a prognostic scoring system. Comment: A MELD score of 30.5 (fixed cut-off level) should be used for prognosis; higher scores predict the need for liver transplantation. […] 6. In patients presenting with ALF, AGA suggests against the routine use of liver biopsy. […] 7. In patients presenting with ALF, AGA suggests autoantibody testing for autoimmune hepatitis be performed. […] 8. In patients presenting with ALF, AGA suggests against the empiric use of treatments to reduce intracranial pressure (ICP). […] 9. In patients presenting with ALF, AGA recommends that extracorporeal artificial liver support systems only be used within the context of a clinical trial. […] 10. In patients presenting with acetaminophen-associated ALF, AGA recommends the use of N-acetyl cysteine (NAC) in acetaminophen-associated ALF. […] 11. In patients presenting with non-acetaminophen-associated ALF, AGA recommends that NAC only be used in the context of clinical trials.

• #2 Acute liver failure differential diagnosis – wikidoc

  https://www.wikidoc.org/index.php/Acute_liver_failure_differential_diagnosis

  Acute liver failure must be differentiated from other diseases that cause signs and symptoms of jaundice, coagulopathy, and encephalopathy. The differentials include acute hepatitis, cholestatic jaundice, and hemolytic jaundice. […] Acute liver failure must be differentiated from other diseases that cause signs and symptoms of jaundice, coagulopathy, and encephalopathy. […] Acute hepatitis would not be considered acute liver failure unless hepatic encephalopathy is present. […] The absence of hepatic encephalopathy and coagulopathy will differentiate it from acute liver failure. […] Liver dysfunction may not be present. So, coagulopathy and hepatic encephalopathy would not be there.

• #2 Differential diagnosis of acute liver failure in India | Annals of Hepatology

  https://www.elsevier.es/en-revista-annals-hepatology-16-articulo-differential-diagnosis-acute-liver-failure-S1665268119319982

  Background: Acute liver failure (ALF) is a condition with rapid deterioration of liver function resulting in hepatic encephalopathy and/or coagulopathy in patients with previously normal liver. […] In developing countries, ALF-mimicking infections should be looked for in differential diagnosis of ALF. Early identification and treatment of these infections is important in reducing mortality. […] In tropical countries like India, where these infections are common; differentiation of ALF due to infectious diseases other than A-E hepatitis viruses (ALF-ID) from ALF due to acute viral A-E hepatitis (ALF-AVH) becomes crucial to provide specific therapy for ALF-ID in addition to supportive treatment for ALF. This study was planned to recognize features that can alert clinicians to suspect these infections in a patient with ALF and differentiate ALF-ID from ALF-AVH.

• #2 Differential diagnosis of acute liver failure in India | Annals of Hepatology

  https://www.elsevier.es/en-revista-annals-hepatology-16-articulo-differential-diagnosis-acute-liver-failure-S1665268119319982

  In a patient presenting with jaundice and encephalopathy (altered mentation) and/or coagulopathy (deranged coagulation parameters with/without systemic bleeding), primary diagnostic consideration is ALF-AVH, which is the commonest form of ALF in India. But, as seen in our study, presence of high grade fever, splenomegaly, mild ALT and AST elevation should make a clinician suspicious about presence of ID other than AVH. […] High index of suspicion and awareness are required to identify various common infections causing symptom complex similar to ALF. This help in identifying a patient with ALF who may have low mortality if specific treatment for such infection is given in time.

• #2 Acute Liver Failure – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK482374/

  The management of ALF consists of supportive care, prevention, and management of complications, specific treatment when the exact etiology is known, and determination of prognosis and the need for liver support including possible liver transplantation. […] The etiology of ALF and the hospital prognosis could help physicians ascertain whether a particular patient is likely to improve or not, and hence need a liver transplant. […] The treatment of ALF depends on the cause but at the same time, all patients need aggressive hydration. […] The outlook for patients with ALF depends on the cause, extent of liver damage, comorbidity, response to treatment, the age of the patient, and the number of organs involved.

• #2 A Comprehensive Review of the Diagnosis and Management of Acute Liver Failure

  https://www.mdpi.com/2077-0383/12/23/7451

  Identifying the etiology is important to guide the treatment and to provide prognostic information. A comprehensive medical history, with a particular emphasis on medications, and herbal and nutritional supplements, within the past six months should be performed. Urine and serum toxicology screenings, urinary ethyl glucuronide, or serum phosphatidyl ethanol should be obtained if alcohol-related liver disease is suspected. If the history, laboratory workup, and imaging findings do not provide any specific etiology for ALF, a liver biopsy might be needed; however, the risks associated with bleeding and death must be accounted for. A routine liver biopsy is not recommended, and if needed, a transjugular liver biopsy is preferred as opposed to a percutaneous liver biopsy. […] ALF can be further categorized as hyperacute, acute, and subacute based on the onset of encephalopathy according to the O’Grady classification. Time frames are defined as <7 days for hyperacute ALF, 7–21 days for acute ALF, and >21 days for subacute ALF. The risk of cerebral edema is highest with hyperacute ALF and lowest with subacute ALF; however, the risk of death is inverse, being lowest with hyperacute ALF and highest with subacute ALF.

• #2 Acute Liver Failure: Symptoms, Causes, Diagnosis, Treatment

  https://www.healthline.com/health/acute-liver-failure

  Acute liver failure can develop rapidly in people with no pre-existing liver disease and requires immediate emergency medical attention. […] Doctors can use the following to help diagnose acute liver failure: a physical exam, review of your personal and family medical history, list of your symptoms and whether you’re taking any drugs or medications, blood tests to look for elevated liver enzymes like alanine and aspartate aminotransferase, which may reach 10 to 100 times the upper limit of normal, abdominal imaging with computed tomography (CT) scans, magnetic resonance imaging (MRI), ultrasound, brain MRI, liver biopsy. […] Acute liver failure tends to have a very poor outlook, although the survival rate has improved with the emergence of emergency liver transplants. The cause of death is often multi-organ failure or swelling in the brain. […] The survival rate for people who don’t receive a liver transplant ranges from about 10% to 40%. People who need a liver transplant now have an expected 1-year survival greater than 65%.

• #2 Acute liver failure: Management update and prognosis | Revista de Gastroenterología de México

  https://www.revistagastroenterologiamexico.org/en-acute-liver-failure-management-update-articulo-S2255534X24000628

  Acute liver failure is a rare but serious syndrome, with an incidence of approximately 2,000 to 3,000 cases per year in North America. […] The most accepted definition includes liver injury with hepatic encephalopathy and coagulopathy within the past 26 weeks in a patient with no previous liver disease. […] Identifying the cause is crucial, given that it influences prognosis and treatment. […] Survival has improved with supportive measures, intensive therapy, complication prevention, and the use of medications, such as N-acetylcysteine. […] Liver transplantation is a curative option for nonresponders to medical treatment, but adequate evaluation of transplantation timing is vital for improving results. […] The probability of spontaneous recovery or transplant-free survival (TFS) is related to etiology and HE grade.

• #2

  https://www.nursingcenter.com/journalarticle?Article_ID=6772781&Journal_ID=54030&Issue_ID=6772618

  Acute liver failure is a life-threatening but potentially reversible condition if identified and managed early. […] It’s critical to distinguish between acute and acute-on-chronic liver failure because management of each is different. […] Early referral to a liver transplant center is a priority. […] The American College of Gastroenterology has issued clinical guidelines that provide a detailed approach to the diagnosis and management of acute liver failure, with emphasis on the importance of early recognition, prompt initiation of treatment, and referral to specialized care. […] Etiology is a key indicator of prognosis and treatment strategy, especially of the need for liver transplant, according to the guidelines. […] Timely referral to a transplant center is essential. […] Patients who have acute liver failure should be referred for hepatology or gastroenterology consultation as soon as possible.

• #2 Liver Failure – End Stage Liver Disease – UChicago Medicine

  https://www.uchicagomedicine.org/conditions-services/liver-diseases-hepatology/liver-failure

  Acute liver failure is a medical emergency, and UChicago Medicine has state-of-the-art intensive care units for monitoring patients with this condition. Treatment will depend on the cause of your underlying liver failure. […] If treatment is not effective, our liver specialists will evaluate you for a possible liver transplant. […] Patients with acute-on-chronic liver failure may see their livers fail over weeks to months, compared to months to years as is typical in chronic liver failure. […] One of the ways we determine if your liver is failing is through blood tests, which help us determine your MELD, or Model for End-Stage Liver Disease, score. […] Your MELD score will range from 6 to more than 40. The worse your liver function, the higher your MELD score will be, and the higher your risk of death. The MELD score is also used to determine a persons priority on the transplant list, with sicker patients receiving higher priority. […] We may also recommend other tests to monitor how well your liver is working.

• #2 Acute liver failure: Management update and prognosis | Revista de Gastroenterología de México

  https://www.revistagastroenterologiamexico.org/en-acute-liver-failure-management-update-articulo-S2255534X24000628

  The mortality rate is 25 to 30% and the main causes of death are sepsis and cerebral edema. […] The definition of ALF varies worldwide, but in the United States and Europe, the most accepted definition is that of a disease lasting less than 26 weeks. […] The main scales for determining disease severity are the Kings College Hospital criteria (KCC) and the Clichy-Villejuif criteria, among others. […] ALF that does not respond to supportive treatment is a clear indication for liver transplantation. […] The transplantation decision should be made in a time lapse not over 3 days, through the evaluation of a multidisciplinary team, with the intention of preventing the clinical deterioration that would contraindicate a liver transplant.

• #3 Acute liver failure – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/1010

  Acute liver failure is a rare, life-threatening, potentially reversible condition defined by jaundice, coagulopathy, and hepatic encephalopathy. […] Aetiology is established by history, serological assays, and exclusion of alternative causes, including acute presentations of chronic liver diseases. […] 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. […] Key diagnostic factors include presence of risk factors, hepatotoxic drugs, chronic alcohol misuse, jaundice, coagulopathy, and signs of hepatic encephalopathy. […] 1st investigations to order include liver function tests, prothrombin time/INR, viscoelastic testing (VET), basic metabolic panel, FBC, blood type and screen, serum amylase and lipase, arterial blood gas, arterial blood lactate, paracetamol level, urine toxicology screen, viral hepatitis serologies, autoimmune hepatitis markers, pregnancy test, chest x-ray, and abdominal ultrasound with Doppler.

• #3 Acute liver failure – Knowledge @ AMBOSS

  https://www.amboss.com/us/knowledge/acute-liver-failure/

  Acute liver failure (ALF) is a severe condition characterized by rapidly progressive liver injury, hepatic encephalopathy, and impaired synthetic function, which results in coagulopathy. […] The diagnosis is confirmed by identifying an elevation of liver chemistries and an altered coagulation panel in patients with encephalopathy. […] Clinicians should maintain a high index of suspicion and aim to confirm the diagnosis as quickly as possible in order to start management early. […] ALF can cause multiorgan dysfunction, which requires system-based management in a critical care unit. […] ALF diagnosis requires the presence of abnormal liver chemistries, coagulopathy (INR 1.5), and encephalopathy. […] Obtain initial laboratory studies to support the diagnosis and assess severity based on organ dysfunction. […] ALF is confirmed if all of the following are present: Encephalopathy, Abnormal liver chemistries, Coagulopathy (INR 1.5). […] In many cases, the cause remains unknown even after an extensive evaluation.

• #3 Acute liver failure – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/acute-liver-failure/diagnosis-treatment/drc-20352868

  Tests and procedures used to diagnose acute liver failure include: […] Blood tests can show how well the liver works. A prothrombin time test measures how long it takes blood to clot. With acute liver failure, blood doesn’t clot as quickly as it should. […] A healthcare professional may recommend an ultrasound exam to look at the liver. Such testing may show liver damage and help find the cause of the liver problems. A health professional also may recommend abdominal computerized tomography (CT) scanning or magnetic resonance imaging (MRI) to look at the liver and blood vessels. These tests can look for certain causes of acute liver failure, such as Budd-Chiari syndrome or tumors. They may be used if a problem is suspected and ultrasound testing does not find the problem. […] A healthcare professional may recommend removing a small piece of liver tissue, called a liver biopsy. Doing so may help discover why the liver is failing.

• #3 Acute Liver Failure – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK482374/

  Acute liver failure is defined as severe acute liver injury for fewer than twenty-six weeks duration with encephalopathy and impaired synthetic function (INR of 1.5 or higher) in a patient without cirrhosis or preexisting liver disease. […] This activity reviews the etiology, evaluation, and management of acute liver failure. […] Outline how to evaluate a patient for acute liver failure. […] A high index of suspicion, early referral to a specialist liver transplantation center, and adequate supportive management remain the cornerstone for the management of ALF. […] An extensive workup for the etiology of ALF is recommended, as this guides directed therapy and helps determine the outcome. […] Prolonged INR greater than or equal to 1.5, often elevated bilirubin and aminotransferases, thrombocytopenia, with anemia, hypoglycemia, elevated ammonia and features of acute renal injury (with elevated serum creatinine), and dyselectrolytemia (hypokalemia, hypophosphatemia) is common.

• #3 Acute liver failure laboratory findings – wikidoc

  https://www.wikidoc.org/index.php/Acute_liver_failure_laboratory_findings

  Acute liver failure can present with nonspecific symptoms and it occurs in healthy individuals without a previous history of liver disease. So, the initial labs in the acute liver failure are planned to evaluate both the etiology and the severity of the disease. All patients with clinical or laboratory evidence of moderate to severe acute hepatitis should have an immediate measurement of prothrombin time and careful evaluation of mental status. If the prothrombin time is prolonged (INR 1.5) and there is any evidence of altered sensorium, the diagnosis of acute liver failure should be strongly suspected and hospital admission is mandatory. […] Prolonged prothrombin time, resulting in an INR 1.5; it shows coagulopathy which is a part of acute liver failure criteria. […] Liver enzymes are elevated in acute liver failure. The decrease in liver enzymes may indicate recovery or worsening of liver failure and an indication of hepatic mass loss.

• #3 Management of Acute Liver Failure | AASLD

  https://www.aasld.org/practice-guidelines/management-acute-liver-failure

  The diagnosis of acute liver failure (ALF) hinges on identifying that the patient has an acute insult and is encephalopathic. […] It is vital to promptly get viral hepatitis serologies, including A-E as well as autoimmune serologies, because these often seem to be neglected at the initial presentation. […] Fulminant Wilsons disease can be diagnosed most effectively not by waiting for copper levels (too slow to obtain) or by obtaining ceruloplasmin levels (low in half of all ALF patients, regardless of etiology), but by simply looking for the more readily available bilirubin level (very high) and alkaline phosphatase (ALP; very low), such that the bilirubin/ALP ratio exceeds 2.0. […] The availability of an assay that measures acetaminophen adducts has been used for several years as a research tool and has improved our clinical recognition of acetaminophen cases when the diagnosis is obscured by patient denial or encephalopathy.

• #3 Acute Liver Failure Workup: Approach Considerations, Laboratory Studies, Blood Cultures

  https://emedicine.medscape.com/article/177354-workup

  The levels of the transaminases (aspartate aminotransferase [AST]/serum glutamic-oxaloacetic transaminase [SGOT], and alanine aminotransferase [ALT]/serum glutamic-pyruvic transaminase [SGPT]) are often elevated dramatically as a result of severe hepatocellular necrosis. […] By definition, the serum bilirubin level should be elevated in fulminant hepatic failure. It climbs as hepatic dysfunction worsens. […] The serum ammonia level may be elevated dramatically in patients with fulminant hepatic failure. […] Serum glucose levels may be dangerously low. […] Arterial blood gas evaluation is valuable for identifying acid-base imbalances. […] Serum creatinine levels may be elevated, signifying the development of hepatorenal syndrome or some other cause of acute renal failure. […] Patients with Wilson disease have low ceruloplasmin and total serum copper levels.

• #3 Acute Liver Failure | Cedars-Sinai

  https://www.cedars-sinai.org/health-library/diseases-and-conditions/a/acute-liver-failure.html

  How is acute liver failure diagnosed? Liver failure is a serious condition. It requires medical care right away. Your healthcare provider will ask about your past health, your use of medicines, illegal drugs, and unregulated natural supplements, and any possible exposure to toxins. You will also need a physical exam. Your healthcare provider may check for signs of hepatitis, such as jaundice, fatigue, and abdominal pain. […] You may also need: Tests for mental alertness, Blood tests. These check your liver enzymes and bilirubin levels. They also measure your blood’s ability to thicken (coagulate). This is called prothrombin time. […] Imaging tests. You may have a CT scan or MRI. These check your liver. […] Acute liver failure is a serious condition. It requires medical care right away.

• #3 A Comprehensive Review of the Diagnosis and Management of Acute Liver Failure

  https://www.mdpi.com/2077-0383/12/23/7451

  Identifying the etiology is important to guide the treatment and to provide prognostic information. A comprehensive medical history, with a particular emphasis on medications, and herbal and nutritional supplements, within the past six months should be performed. Urine and serum toxicology screenings, urinary ethyl glucuronide, or serum phosphatidyl ethanol should be obtained if alcohol-related liver disease is suspected. If the history, laboratory workup, and imaging findings do not provide any specific etiology for ALF, a liver biopsy might be needed; however, the risks associated with bleeding and death must be accounted for. A routine liver biopsy is not recommended, and if needed, a transjugular liver biopsy is preferred as opposed to a percutaneous liver biopsy. […] ALF can be further categorized as hyperacute, acute, and subacute based on the onset of encephalopathy according to the O’Grady classification. Time frames are defined as <7 days for hyperacute ALF, 7–21 days for acute ALF, and >21 days for subacute ALF. The risk of cerebral edema is highest with hyperacute ALF and lowest with subacute ALF; however, the risk of death is inverse, being lowest with hyperacute ALF and highest with subacute ALF.

• #3 Differential diagnosis of acute liver failure in India | Annals of Hepatology

  https://www.elsevier.es/en-revista-annals-hepatology-16-articulo-differential-diagnosis-acute-liver-failure-S1665268119319982

  In a patient presenting with jaundice and encephalopathy (altered mentation) and/or coagulopathy (deranged coagulation parameters with/without systemic bleeding), primary diagnostic consideration is ALF-AVH, which is the commonest form of ALF in India. But, as seen in our study, presence of high grade fever, splenomegaly, mild ALT and AST elevation should make a clinician suspicious about presence of ID other than AVH. […] High index of suspicion and awareness are required to identify various common infections causing symptom complex similar to ALF. This help in identifying a patient with ALF who may have low mortality if specific treatment for such infection is given in time.

• #3 Defining and Managing Acute Liver Failure | AASLD

  https://www.aasld.org/liver-fellow-network/core-series/back-basics/defining-and-managing-acute-liver-failure

  Multiple prognostic scores have been developed for ALF. One of the most well-known and utilized is the Kings College Criteria (KCC). […] Although improvements in medical care have significantly lowered mortality rates, LT is being implemented in approximately 30% of patients with ALF, and offers a life-saving treatment. […] Early referral to a LT center should be pursued as soon as ALF is clinically suspected in order to expedite transplant evaluation for patients who need it.

• #3 Acute liver failure: Management update and prognosis | Revista de Gastroenterología de México

  https://www.revistagastroenterologiamexico.org/en-acute-liver-failure-management-update-articulo-S2255534X24000628

  The mortality rate is 25 to 30% and the main causes of death are sepsis and cerebral edema. […] The definition of ALF varies worldwide, but in the United States and Europe, the most accepted definition is that of a disease lasting less than 26 weeks. […] The main scales for determining disease severity are the Kings College Hospital criteria (KCC) and the Clichy-Villejuif criteria, among others. […] ALF that does not respond to supportive treatment is a clear indication for liver transplantation. […] The transplantation decision should be made in a time lapse not over 3 days, through the evaluation of a multidisciplinary team, with the intention of preventing the clinical deterioration that would contraindicate a liver transplant.

• #3

  https://www.nursingcenter.com/journalarticle?Article_ID=6772781&Journal_ID=54030&Issue_ID=6772618

  Acute liver failure is a life-threatening but potentially reversible condition if identified and managed early. […] It’s critical to distinguish between acute and acute-on-chronic liver failure because management of each is different. […] Early referral to a liver transplant center is a priority. […] The American College of Gastroenterology has issued clinical guidelines that provide a detailed approach to the diagnosis and management of acute liver failure, with emphasis on the importance of early recognition, prompt initiation of treatment, and referral to specialized care. […] Etiology is a key indicator of prognosis and treatment strategy, especially of the need for liver transplant, according to the guidelines. […] Timely referral to a transplant center is essential. […] Patients who have acute liver failure should be referred for hepatology or gastroenterology consultation as soon as possible.

• #3 Management of acute liver failure. Clinical guideline from the Catalan Society of Digestology | Gastroenterología y Hepatología (English Edition)

  https://www.elsevier.es/en-revista-gastroenterologia-hepatologia-english-edition–382-articulo-management-acute-liver-failure-clinical-S2444382419300124

  The diagnosis of ALF in paediatric patients does not depend on the development of HE (grade of evidence II-3, grade of recommendation 1). […] Once the diagnosis of ALF is established, i.e. after they develop HE, regardless of the suspected aetiology, the patient should be moved to an ICU in a centre capable of performing ELT. […] 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 (grade of evidence III, grade of recommendation 1). […] 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 (grade of evidence III, grade of recommendation 2).

• #3 Acute liver failure | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/acute-liver-failure?lang=us

  Acute liver failure (ALF), also known as fulminant hepatic failure, refers to sudden severe liver dysfunction from injury without underlying chronic liver disease (CLD), although sometimes it presents as decompensation of unknown chronic liver disease. […] Symptoms and signs of hepatic encephalopathy and/or coagulopathy is the most common presentation. […] A diagnosis of Budd-Chiari syndrome, ischemic hepatitis, and portal vein thrombosis may be confirmed or excluded during workup. […] Mortality is high in acute liver failure at ~50% (range 30-70%) with orthotopic liver transplant considered the definitive treatment. […] The goals of management include identification of reversible causes of acute liver failure, provide organ support to maximize the probability of recovery as well as to perform risk stratification and identify patients for consideration of early liver transplantation, as they may not survive supportive care.

• #4 Management of Acute Liver Failure | AASLD

  https://www.aasld.org/practice-guidelines/management-acute-liver-failure

  Any patient with very high aminotransferases and low bilirubin on admission with ALF very likely has acetaminophen overdose, with the one possible exception being those patients who enter with ischemic injury. […] Obtaining autoantibodies should be routine and a low threshold for biopsy in patients with indeterminate ALF should be standard, given that autoimmune hepatitis may be the largest category of indeterminate, after unrecognized acetaminophen poisoning.

• #4 Defining and Managing Acute Liver Failure | AASLD

  https://www.aasld.org/liver-fellow-network/core-series/back-basics/defining-and-managing-acute-liver-failure

  Acute liver failure (ALF) is defined by the following criteria: […] Outline preliminary diagnostic workup to guide management of acute liver failure. […] The liver enzyme pattern can give preliminary clues to the etiology of ALF. […] A comprehensive laboratory work up should be sent that evaluates the differential diagnosis and prepares for the prospect of a liver transplant evaluation. […] Repeated lab monitoring every few hours also helps with real-time prognostication of which patients may be improving with support, versus which are progressing and need timely transplant evaluation. […] Liver biopsy may be needed if the laboratory workup or imaging findings do not provide a specific etiology for ALF, however risks with bleeding should be taken into account. […] Cross-sectional abdominal imaging with contrast is ideal to survey the hepatic anatomy, vasculature, and inform potential surgical planning for liver transplantation; if this is not possible due to patient acuity, an ultrasound doppler of the liver at the patients bedside should be obtained in the interim.

• #4 Diagnosis and management of acute liver failure – American Gastroenterological AssociationAGA Logo_Horizontal

  https://gastro.org/clinical-guidance/diagnosis-and-management-of-acute-liver-failure/

  4. In pregnant women presenting with ALF, AGA suggests testing for hepatitis E. […] 5. In patients presenting with ALF, AGA suggests using the Model for End-Stage Liver Disease (MELD) score rather than the Kings College Criteria (KCC) as a prognostic scoring system. Comment: A MELD score of 30.5 (fixed cut-off level) should be used for prognosis; higher scores predict the need for liver transplantation. […] 6. In patients presenting with ALF, AGA suggests against the routine use of liver biopsy. […] 7. In patients presenting with ALF, AGA suggests autoantibody testing for autoimmune hepatitis be performed. […] 8. In patients presenting with ALF, AGA suggests against the empiric use of treatments to reduce intracranial pressure (ICP). […] 9. In patients presenting with ALF, AGA recommends that extracorporeal artificial liver support systems only be used within the context of a clinical trial. […] 10. In patients presenting with acetaminophen-associated ALF, AGA recommends the use of N-acetyl cysteine (NAC) in acetaminophen-associated ALF. […] 11. In patients presenting with non-acetaminophen-associated ALF, AGA recommends that NAC only be used in the context of clinical trials.

• #4 Defining and Managing Acute Liver Failure | AASLD

  https://www.aasld.org/liver-fellow-network/core-series/back-basics/defining-and-managing-acute-liver-failure

  Multiple prognostic scores have been developed for ALF. One of the most well-known and utilized is the Kings College Criteria (KCC). […] Although improvements in medical care have significantly lowered mortality rates, LT is being implemented in approximately 30% of patients with ALF, and offers a life-saving treatment. […] Early referral to a LT center should be pursued as soon as ALF is clinically suspected in order to expedite transplant evaluation for patients who need it.

• #4 Management of acute liver failure. Clinical guideline from the Catalan Society of Digestology | Gastroenterología y Hepatología (English Edition)

  https://www.elsevier.es/en-revista-gastroenterologia-hepatologia-english-edition–382-articulo-management-acute-liver-failure-clinical-S2444382419300124

  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 (grade of evidence III, grade of recommendation 1). […] The assessment of the patient’s prognosis must be carried out continuously in order to decide on the best therapeutic option at all stages (grade of evidence III, grade of recommendation 1). […] Patients with ALF requiring an ELT should be put on a priority transplant list (grade of evidence III, grade of recommendation 1).

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