O slideshow foi denunciado.
Utilizamos seu perfil e dados de atividades no LinkedIn para personalizar e exibir anúncios mais relevantes. Altere suas preferências de anúncios quando desejar.

Acute Liver Failure

6.951 visualizações

Publicada em

Acute Liver Failure, Gastroenterology, Hepatology, IM, Internal Medicine, CDUH, Cebu, Evardone

Publicada em: Saúde e medicina
  • Login to see the comments

Acute Liver Failure

  1. 1. ACUTE LIVER FAILURE Jose Socrates ‘Dee’ Matuod Evardone Gastro 2 Year Level II CDUH-IM
  2. 2. ACUTE LIVER FAILURE • SOURCES:
  3. 3. CASE • PATIENT PROFILE • G.R. 26 yo • Male • Single • Non-DM • Non-HTN • PTB (maintenance) on HRZE x 2 months • HIV, Hep B • Bisexual orientation • CHIEF COMPLAINT: Disorientation
  4. 4. CASE • HPI • 4 weeks PTA, • noted yellowish skin discoloration • Body malaise • Loss of appetite • Mild epigastric pain • Maculopapular rashes • Consulted his AP, Labs taken showed elevated SGPT • Admitted 6 days PTA • admitted for 4 days, treated as drug induced liver injury secondary to Anti- TB meds, • with Elevated INR, Elevated SGPT, no encephalopathy • Discharged 1 day PTA • That night on discharge day, px noted to be disoriented and became incoherent, thus he was brought back for readmission • (-) fever, (-)diarrhea, (-) vomiting, • No Hx of fall, head trauma
  5. 5. CASE • Maintenance meds 1. Phospholipids Essentiale Forte 2. Vitamin K 3. Fluimucil 4. Ursodeoxycholic acid 5. Hydroxyzine 6. Mycostatin
  6. 6. Physical Exam Lethargic, incoherent, NIRD, Warm, good turgor and mobility, CRT <2 seconds, Generalized Jaundice, Maculopapular rashes Icteric sclerae, pink palpebral conjunctivae, Equal chest expansion, dec BS on the Right lower quadrant Distinct heart sounds, tachycardic, regular rhythm Flat, Normoactive bowel sounds, soft, direct tenderness on RUQ, Hepatomegaly, no splenomegaly, no fluid wave Strong peripheral pulses, no edema, Neurologic: Lethargic, but arousable, not cooperative BP: 110/80mmHg, HR: 129bpm, RR: 20cpm, Temp: 36.5°C CN II, III: Isocoric, round, brisk, OU CN III, IV, VI: n/a CN VII: no facial asymmetry CN XII: n/a Sensory: n/a Motor Strength: 5/5 Reflexes: +2 DTRs (-) Babinski (-) Meningeal signs NO asterixis
  7. 7. LABSCBC Adm Hgb 10.7 Hct 31.6 WBC Seg Bas Eos Lymph Mono 9.9 79 0 1 10 10 RBC 4.95 Platelet 88.5 MCV MCH MCHC 85.6 29 33.9 CHEMISTRY Creatinine 0.78 Potassium 2.4 SGPT 376 Albumin 1.8 Globulin 5.7 Total Prot 7.5 Prothrombin Time Control 10.7 sec Pro Time 85.4 sec % Activity 5.8 INR 7.03
  8. 8. CASE IMPRESSION 1. Acute Liver Failure secondary to Anti-TB Medications 2. Hepatic EncephalopathyGrade 1-2, sec to #1 3. Hypokalemia sec to #1 4. HIV 5. Hepatitis B Infection
  9. 9. ACUTE LIVER FAILURE • DEFINITIONS • ETIOLOGY and EPIDEMIOLOGY • Viral hepatitis • Acetaminophen and other hepatotoxins • Idiosyncratic drug reactions • Hypoperfusion • CLINICAL MANIFESTATIONS • Symptoms • Physical examination findings • - Neurologic examination • - Other physical examination findings • Laboratory test abnormalities • - Laboratory findings associated with specific diagnoses • Imaging and other studies • DIAGNOSIS • Diagnosing acute liver failure • Determining the cause of acute liver failure • -Timing of the evaluation • - History • - Physical examination • - Laboratory evaluation • - Imaging studies • - Liver biopsy
  10. 10. ACUTE LIVER FAILURE • APPROACHTO MANAGEMENT • Overall Strategy • General Measures • DIFFERENTIAL DIAGNOSIS • TREATMENT OF COMPLICATIONS • NeurologicComplications • Infection • Hemodynamic Instability and Hypoxemia • Renal Failure • Coagulopathy • Metabolic Disorders • Nutritional Deficiencies • PROGNOSIS • LIVERTRANSPLANTATION • EXTRACORPOREAL LIVER SUPPORT
  11. 11. The Liver as an Organ
  12. 12. The Liver as an Organ LIVER’S DIFFERENT FUNCTIONS: (1) FILTRATION AND STORAGE OF BLOOD; (2) METABOLISM OF a) carbohydrates, b) proteins, c) fats, d) hormones, and e) foreign chemicals; (3) FORMATION OF BILE; (4) STORAGE OF VITAMINS AND IRON; AND (5) FORMATION OF COAGULATION FACTORS
  13. 13. ACUTE LIVER FAILURE INTRODUCTION ACUTE LIVER FAILURE IS CHARACTERIZED BY 1. ACUTE LIVER INJURY, 2. HEPATIC ENCEPHALOPATHY, AND 3. AN ELEVATED PROTHROMBIN TIME/INTERNATIONAL NORMALIZED RATIO (INR) IT HAS ALSO BEEN REFERRED TO AS  fulminant hepatic failure,  acute hepatic necrosis,  fulminant hepatic necrosis, and  fulminant hepatitis.
  14. 14. ACUTE LIVER FAILURE DEFINITION ACUTE LIVER FAILURE REFERS TO THE DEVELOPMENT OF AND IN A PATIENT WITHOUT CIRRHOSIS OR PREEXISTING LIVER DISEASE ENCEPHALOPATHY impaired synthetic function (INR of ≥1.5) < 26 WEEKS SEVERE ACUTE LIVER INJURY
  15. 15. ACUTE LIVER FAILURE DEFINITION A NUMBER OF OTHER TERMS HAVE BEEN USED FOR THIS CONDITION, INCLUDING FULMINANT HEPATIC FAILURE AND FULMINANT HEPATITIS OR NECROSIS. One categorization based on clinical patterns and outcome described 3 groups based on the time interval between the onset of jaundice and encephalopathy:(8 weeks to 6 months) A. Hyperacute liver failure (7 days or less), B. ALF (8 to 28 days), and C. Subacute liver failure (4 to 24 weeks)
  16. 16. ACUTE LIVER FAILURE ETIOLOGY AND EPIDEMIOLOGY
  17. 17. ACUTE LIVER FAILURE ETIOLOGY AND EPIDEMIOLOGY THREE PATTERNS OF ALF ARE ASSOCIATED WITH DRUGS: 1. DOSE-RELATED, 2. IDIOSYNCRATIC, AND 3. HYPERSENSITIVITY REACTIONS drug-induced liver injury (DILI) 46% were antimicrobials and 15% were central nervous system agents The mortality rate was 3% to 4%
  18. 18. ACUTE LIVER FAILURE ETIOLOGY AND EPIDEMIOLOGY SOME DRUGS, HERBAL PRODUCTS, AND TOXINS ASSOCIATED WITH ACUTE LIVER FAILURE Abacavir Comfrey He Shon Wu MDMA (Ecstasy) Pyrazinamide Acetaminophen (paracetamol) Dapsone Herbalife® Methamphetamine Rifampin Alcohol Didanosine Hydroxycut® Monoamine oxidase inhibitors Senecio Allopurinol Dideoxyinosine Isoflurane Methyldopa Statins Amiodarone Disulfiram Isoniazid Nicotinic acid Sulfonamides Amoxicillin Doxycycline Itraconazole Nitrofurantoin Terbinafine Aspirin Efavirenz Kava Kava NSAIDS Tetracycline Carbamazepine Gemtuzumab Ketoconazole Phenprocoumon Tolcapone Carbon tetrachloride Gold Labetalol Phenytoin Tricyclic antidep. Ciprofloxacin Greater celandine LipoKinetix® Poison mushrooms (Amanita phalloides) Valproic acid Cocaine Halothane Ma Huang Propylthiouracil
  19. 19. ACUTE LIVER FAILURE ETIOLOGY AND EPIDEMIOLOGY: DRUGS ACETAMINOPHEN -PARTIALLY DOSE-DEPENDENT HEPATOTOXIN WITH MORTALITY HIGHEST AT DOSES EXCEEDING 48G -INCREASED SUSCEPTIBILITY TO ACETAMINOPHEN TOXICITY: a) Antiepileptic therapy, b) Regular alcohol consumption, and c) Malnutrition -DIRECT TOXIN TO OTHER ORGANS - N-ACETYLCYSTEINE AS ANTIDOTE IN 16HOURS - MOST COMMON CAUSE OF ALF IN THE UNITED KINGDOM AND THE UNITED STATES
  20. 20. ACUTE LIVER FAILURE ETIOLOGY AND EPIDEMIOLOGY: IDIOSYNCRATIC REACTIONS (DILI) THE DIAGNOSIS OF DILI IS MADE WHEN THERE IS A TEMPORAL RELATIONSHIP (DRESS)- DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS
  21. 21. ACUTE LIVER FAILURE
  22. 22. ACUTE LIVER FAILURE
  23. 23. ACUTE LIVER FAILURE ETIOLOGY AND EPIDEMIOLOGY VIRAL INFECTIONS 1) HAV-RELATED ALF: 2) HBV-RELATED ALF: 3) HEPATITIS D: 4) HEPATITIS E: 5) HSV-1, 2, AND 6, VARICELLA-ZOSTER VIRUS, EBV, CYTOMEGALOVIRUS, AND PARVOVIRUS B19
  24. 24. ACUTE LIVER FAILURE ETIOLOGY AND EPIDEMIOLOGY: RARE CAUSES 1. PREGNANCY-RELATED ACUTE LIVER FAILURE -- - 0.0008%, 1ST PREG AND MALE FETUS - ALF of pregnancy, preeclampsia, and the HELLP syndrome 2. VASCULAR CAUSES - Hepatic vein thrombosis, or Budd-Chiari syndrome 3. HYPERTHERMIA -cause may be a drug reaction 4. AUTOIMMUNE HEPATITIS - strongly positive autoantibodies and elevated serum IgG 5. WILSON DISEASE - alkaline phosphatase: total bilirubin= < 4 - AST: ALT = > 2.2 6. MUSHROOM POISONING Severe diarrhea and vomiting , ALF in 4-5 days
  25. 25. ACUTE LIVER FAILURE ETIOLOGY AND EPIDEMIOLOGY HYPOPERFUSION HYPOPERFUSION OF THE LIVER CAN RESULT IN ISCHEMIC HEPATITIS AND ACUTE LIVER FAILURE. HYPOPERFUSION MAY RESULT FROM: 1. SYSTEMIC HYPOTENSION DUE TO CAUSES SUCH AS CARDIAC DYSFUNCTION, SEPSIS, OR DRUGS. 2. BUDD-CHIARI SYNDROME (HEPATIC VEIN THROMBOSIS), 3. VENO-OCCLUSIVE DISEASE, OR 4. THE USE OF VASOCONSTRICTING DRUGS SUCH AS COCAINE AND METHAMPHETAMINE.
  26. 26. ACUTE LIVER FAILURE CLINICAL MANIFESTATIONS SYMPTOMS ●FATIGUE/MALAISE ●LETHARGY ●ANOREXIA ●NAUSEA AND/OR VOMITING ●RIGHT UPPER QUADRANT PAIN ●PRURITUS ●JAUNDICE ●ABDOMINAL DISTENSION FROM ASCITES
  27. 27. ACUTE LIVER FAILURE CLINICAL FEATURES ●ENCEPHALOPATHY ●INTRACRANIAL HYPERTENSION AND CEREBRAL EDEMA ●HEMODYNAMIC CHANGES AND CIRCULATORY FAILURE ●INFECTION ●RENAL FAILURE ●HEMATOLOGIC ABNORMALITIES
  28. 28. ACUTE LIVER FAILURE CLINICAL FEATURES: ENCEPHALOPATHY -mandatory for a diagnosis of ALF -classically graded on a scale of 1 to 4 -The briefest period between liver injury and the development of encephalopathy is 3 to 4 days
  29. 29. ACUTE LIVER FAILURE CLINICAL MANIFESTATIONS PHYSICAL EXAMINATION FINDINGS
  30. 30. ACUTE LIVER FAILURE CLINICAL FEATURES: INTRACRANIAL HYPERTENSION AND CEREBRAL EDEMA CEREBRAL EDEMA:  HALLMARK COMPLICATION OF ALF,  MAJOR CAUSE OF DEATH, AND  THREAT TO SUCCESSFUL LT DEVELOPED IN UP TO 80% OF PATIENTS WITH GRADE 3 TO 4 ENCEPHALOPATHY
  31. 31. ACUTE LIVER FAILURE CLINICAL FEATURES: INTRACRANIAL HYPERTENSION AND CEREBRAL EDEMA THE CLINICAL FEATURES OF CEREBRAL EDEMA 1. systemic hypertension, 2. decerebrate posturing, 3. hyperventilation, 4. Abnormal pupillary reflexes, and ultimately impairment of brainstem reflexes and functions The outcome with medical management is usually either full recovery or death
  32. 32. ACUTE LIVER FAILURE CLINICAL FEATURES: INTRACRANIAL HYPERTENSION AND CEREBRAL EDEMA
  33. 33. ACUTE LIVER FAILURE CLINICAL FEATURES: HEMODYNAMIC CHANGES AND CIRCULATORY FAILURE Hyperdynamic circulation • increased cardiac output, and reduced systemic peripheral vascular resistance Circulatory failure • falling cardiac output • inability to maintain an adequate mean arterial pressure Cardiac arrhythmias • hypo- or hyperkalemia, acidosis, • hypoxia, or • cardiac irritation by a central venous catheter.
  34. 34. ACUTE LIVER FAILURE CLINICAL FEATURES: INFECTION - 2X THE RISK - COMMON CAUSE OF DEATH - DEFECTIVE NEUTROPHIL FUNCTION - GRADE 2 & UP, 80% BACTERIAL, 32% FUNGAL - CULTURE SOURCES - Blood, Urine, sputum and vascular cannulae - PREDOMINANT BACTERIA - Staphylococcus aureus, Streptococci, and coliform bacteria - RISK FACTORS FOR BOTH BACTERIAL AND FUNGAL SEPSIS INCLUDE: - coexisting renal failure, - cholestasis, - treatment with a barbiturate, and - Liver transplant
  35. 35. ACUTE LIVER FAILURE CLINICAL FEATURES: RENAL FAILURE - 75% OF PATIENTS FOLLOWING AN ACETAMINOPHEN OVERDOSE - 30% OF PATIENTS WITH OTHER ETIOLOGIES - RENAL FAILURE AFTER AN ACETAMINOPHEN - direct renal toxicity and - develops early in the course of the illness and - in parallel with liver injury - EARLY RENAL DYSFUNCTION MAY ALSO BE SEEN IN - Wilson disease, - mushroom poisoning, and - pregnancy-related syndromes
  36. 36. ACUTE LIVER FAILURE CLINICAL FEATURES: RENAL FAILURE - NON-ACETAMINOPHEN CASES, PROGRESSING FROM A STAGE OF: - functional, or prerenal, - failure (urinary sodium < 10 mmol/L, urine/plasma osmolarity ratio > 1.1) - to acute tubular necrosis
  37. 37. ACUTE LIVER FAILURE CLINICAL FEATURES: HEMATOLOGIC ABNORMALITIES -DECREASED CIRCULATING LEVELS OF FIBRINOGEN, PROTHROMBIN, AND FACTORS V, VII, IX, AND X - PARAMETERS: - prothrombin time, the INR and the individual factor levels - EVIDENCE OF INCREASED PERIPHERAL CONSUMPTION - OVERT DIC OBSERVED IN PREGNANCY-RELATED SYNDROMES - DECREASED ANTICOAGULANT PROTEINS: - proteins C and S, antithrombin - RISK OF BLEEDING IS MUCH MORE CLOSELY LINKED TO THE PLATELET COUNT - INCREASED LEVELS OF CIRCULATING VON WILLEBRAND FACTOR
  38. 38. ACUTE LIVER FAILURE CLINICAL FEATURES: HEMATOLOGIC ABNORMALITIES - PLATELET COUNTS BELOW 100,000/MM3 ARE SEEN IN UP TO 70% OF PATIENTS - A COOMBS-NEGATIVE HEMOLYTIC ANEMIA IS A CHARACTERISTIC OF WILSON DISEASE - COOMBS-POSITIVE HEMOLYTIC ANEMIA MAY BE SEEN IN ALF ASSOCIATED WITH AUTOIMMUNE HEPATITIS - ERYTHROHEMOPHAGOCYTOSIS- POOR PROGNOSIS
  39. 39. ACUTE LIVER FAILURE DIAGNOSIS
  40. 40. ACUTE LIVER FAILURE DIAGNOSIS
  41. 41. ACUTE LIVER FAILURE DIAGNOSIS ACUTE LIVER FAILURE IS DIAGNOSED BY DEMONSTRATING ALL OF THE FOLLOWING: I. ELEVATED AMINOTRANSFERASES (often with abnormal bilirubin and alkaline phosphatase levels II. HEPATIC ENCEPHALOPATHY III.PROLONGED PROTHROMBIN TIME (INR ≥1.5)
  42. 42. ACUTE LIVER FAILURE LABORATORY TEST ABNORMALITIES ●PROLONGED PROTHROMBIN TIME, RESULTING IN AN INR ≥1.5 (THIS FINDING IS PART OF THE DEFINITION OF ACUTE LIVER FAILURE AND THUS MUST BE PRESENT); ●ELEVATED AMINOTRANSFERASE LEVELS (OFTEN MARKEDLY ELEVATED) ●ELEVATED BILIRUBIN LEVEL ●LOW PLATELET COUNT (≤150,000/MM3)
  43. 43. ACUTE LIVER FAILURE OTHER LABORATORY TEST ABNORMALITIES ●ANEMIA ●ELEVATED SERUM CREATININE AND BLOOD UREA NITROGEN ●ELEVATED AMYLASE AND LIPASE ●HYPOGLYCEMIA ●HYPOPHOSPHATEMIA ●HYPOMAGNESEMIA ●HYPOKALEMIA ●ACIDOSIS OR ALKALOSIS ●ELEVATED AMMONIA LEVEL ●ELEVATED LACTATE DEHYDROGENASE (LDH) LEVEL
  44. 44. ACUTE LIVER FAILURE LABORATORY FINDINGS ASSOCIATED WITH SPECIFIC DIAGNOSES: ACETAMINOPHEN: • VERY HIGH AMINOTRANSFERASE LEVELS (>3500 INT. UNIT/L), • LOW BILIRUBIN, • HIGH INR ISCHEMIC HEPATIC INJURY: • VERY HIGH AMINOTRANSFERASE LEVELS (25 TO 250 TIMES THE UPPER LIMIT OF NORMAL), • ELEVATED SERUM LDH LEVELS HEPATITIS B: • AMINOTRANSFERASE LEVELS OF TO 1000 TO 2000 INT. UNIT/L • ALT>AST
  45. 45. ACUTE LIVER FAILURE LABORATORY FINDINGS ASSOCIATED WITH SPECIFIC DIAGNOSES: WILSON DISEASE: • COOMBS-NEGATIVE HEMOLYTIC ANEMIA, • AMINOTRANSFERASE LEVELS <2000 INT. UNIT/L, • AST:ALT >2, • NORMAL OR MARKEDLY SUBNORMAL ALKALINE PHOSPHATASE (<40 INT. UNIT/L), • ALKALINE PHOSPHATASE (INT. UNIT/L) TO TOTAL BILIRUBIN (MG/DL) RATIO <4, • RAPIDLY PROGRESSIVE RENAL FAILURE, • LOW URIC ACID LEVELS ACUTE FATTY LIVER OF PREGNANCY/HELLP SYNDROME: • AMINOTRANSFERASE LEVELS <1000 INT. UNIT/L, • ELEVATED BILIRUBIN, • LOW PLATELET COUNT
  46. 46. ACUTE LIVER FAILURE LABORATORY FINDINGS ASSOCIATED WITH SPECIFIC DIAGNOSES: HERPES SIMPLEX VIRUS: • MARKEDLY ELEVATED TRANSAMINASES, • LEUKOPENIA, • LOW BILIRUBIN REYE SYNDROME, VALPROATE TOXICITY, OR TETRACYCLINE TOXICITY: • MINOR TO MODERATE ELEVATIONS IN AMINOTRANSFERASE AND BILIRUBIN LEVELS
  47. 47. ACUTE LIVER FAILURE APPROACH TO MANAGEMENT OVERALL STRATEGY - SURVIVAL RATES IN ALF HAVE IMPROVED DRAMATICALLY - OVER 60% OF PATIENTS CAN BE EXPECTED TO SURVIVE THE ILLNESS - THE KING’S COLLEGE HOSPITAL EXPERIENCE FROM 1973 TO 2008 - improvement in care and LiverTransplant - increase in overall survival from 16.7% to 62.2%, with rates of - 86% for those undergoing LT and - 48% for those managed medically - TIME IS OF THE ESSENCE
  48. 48. ACUTE LIVER FAILURE APPROACH TO MANAGEMENT: OVERALL STRATEGY
  49. 49. ACUTE LIVER FAILURE APPROACH TO MANAGEMENT GENERAL MEASURES - ADEQUATE FLUID RESUSCITATION - PARENTERAL VITAMIN K - N-ACETYLCYSTEINE, - within 15 hours - No benefit for non-acetaminophen ALF - transplant-free survival was significantly better in patients with grade 1 to 2 encephalopathy - FAST-ACTING ANTIVIRAL DRUGS EFFECTIVE AGAINST HBV - SILYMARIN- MUSHROOM POISONING - D-PENICILLAMINE – WILSON’S - GLUCOCORTICOID THERAPY – NO BENEFIT
  50. 50. ACUTE LIVER FAILURE DIFFERENTIAL DIAGNOSIS A) SEVERE ACUTE HEPATITIS THE PRIMARY ENTITY IN THE DIFFERENTIAL DIAGNOSIS HAVE JAUNDICE AND COAGULOPATHY BUT LACK SIGNS OF HEPATIC ENCEPHALOPATHY B) NEUROLOGIC WILSON DISEASE PRESENCE OF DYSARTHRIA, DYSTONIA, TREMORS, OR PARKINSONISM BEEN PRESENT PRIOR TO THE ONSET OF THE HEPATIC MANIFESTATIONS C) SEVERE ACUTE ALCOHOLIC HEPATITIS OVER THE COURSE OF WEEKS TO MONTHS AST:ALT 2:1 DOES NOT EXCLUDE OTHER CAUSES OF ALF
  51. 51. ACUTE LIVER FAILURE TREATMENT OF COMPLICATIONS: NEUROLOGIC - PROTECTION OF THE PATIENT’S AIRWAY, AND - ENDOTRACHEAL INTUBATION AND MECHANICAL VENTILATION ARE INDICATED ONCE GRADE 3 ENCEPHALOPATHY DEVELOPS - ADEQUATE ANALGESIA AND SEDATION ARE REQUIRED -PROPOFOL AND FENTANYL - REDUCTION OF THE RISK OF CEREBRAL EDEMA ARE INSTITUTED - EXPERIMENTAL APPROACHES (NO SURVIVAL BENEFIT) - branched-chain amino acids, - the benzodiazepine antagonist flumazenil, and - extracorporeal liver support devices
  52. 52. ACUTE LIVER FAILURE TREATMENT OF COMPLICATIONS: NEUROLOGIC - THE MAIN NEUROLOGIC COMPLICATION AMENABLE TO THERAPY IS CEREBRAL EDEMA - Mannitol - hypertonic saline (3%) - HYPERVENTILATION - ONLY BE USED AS AN EMERGENCY MEASURE IN REFRACTORY CASES - HYPOTHERMIA (BODY TEMPERATURE REDUCED TO 32° TO 33°C) - PHENOBARBITAL (OR SODIUM THIOPENTAL) AND IV INDOMETHACIN - HEPATECTOMY
  53. 53. ACUTE LIVER FAILURE TREATMENT OF COMPLICATIONS: INFECTION - PROPHYLACTIC ANTIBIOTICS - REDUCTION IN INFECTION RATES - NO BENEFIT - SMALL BOWEL DECONTAMINATION - Not effective
  54. 54. ACUTE LIVER FAILURE TREATMENT OF COMPLICATIONS: HEMODYNAMIC INSTABILITY AND HYPOXEMIA - INVASIVE HEMODYNAMIC MONITORING - COLLOID, CRYSTALLOID FLUIDS, AND BLOOD PRODUCTS - VASOPRESSORS - may cause or aggravate hypoxia - epoprostenol (prostacyclin) infused at a rate of 5 ng/kg/min when used in conjunction with both norepinephrine and epinephrine - HYDROCORTISONE - For inotropic resistant, hypoadrenal profile - cosyntropin stimulation test or short tetracosactide test
  55. 55. ACUTE LIVER FAILURE TREATMENT OF COMPLICATIONS: RENAL FAILURE • AN EARLY FLUID CHALLENGE IS INDICATED IN PATIENTS IN WHOM OLIGURIA OR BIOCHEMICAL EVIDENCE OF RENAL DYSFUNCTION DEVELOPS • EXTRACORPOREAL RENAL SUPPORT HAS BEEN REQUIRED • 75% of cases of acetaminophen-induced ALF • 30% of cases due to other • EARLY INTERVENTION WITH HEMODIALYSIS
  56. 56. ACUTE LIVER FAILURE TREATMENT OF COMPLICATIONS: COAGULOPATHY FRESH FROZEN PLASMA - PROPHYLACTIC REPLETION - failed to demonstrate an improvement in survival and - was thought to be detrimental in a minority of patients - interferes with the use of coagulation studies - fluid overload and - hyperviscosity syndrome - RECOMBINANT FACTOR VIIA - Limited data - > 50,000 TO 70,000/MM3 PLATELETS - has been recommended
  57. 57. ACUTE LIVER FAILURE TREATMENT OF COMPLICATIONS: METABOLIC DISORDERS - HYPOGLYCEMIA - mistaken for the onset of advanced encephalopathy - METABOLIC ACIDOSIS - acetaminophen overdose, high mortality of at least 90% if the arterial pH is below 7.30 on the second or subsequent days after the overdose - HYPERLACTATEMIA - HYPOKALEMIA - Associated with alkalosis - HYPONATREMIA - Vomiting, dilutional, intracellular sodium shifts - HYPOPHOSPHATEMIA - acetaminophen-induced ALF - HYPOMAGNESEMIA
  58. 58. ACUTE LIVER FAILURE TREATMENT OF COMPLICATIONS: NUTRITIONAL DEFICIENCIES - CATABOLIC PROCESS CAN BE PROFOUND - INFLUENCED BY THE THEORETICAL ROLE OF AMINO ACID RATIOS IN MEDIATING ENCEPHALOPATHY - ENTERAL NUTRITION IS DESIRABLE - FEEDING IS NORMALLY COMMENCED WITHIN 24 HOURS OF ADMISSION TO AN ICU - GOAL OF 25 TO 30 KCAL/ KG/DAY
  59. 59. ACUTE LIVER FAILURE PROGNOSIS OVERALL SURVIVAL RATES >60% 40% OF PATIENTS SURVIVES W/O NEEDING LT THREE IMPORTANT DETERMINANTS OF OUTCOME - UNDERLYING ETIOLOGY OF ALF, - AGE OF THE PATIENT, AND - GRADE OF ENCEPHALOPATHY EARLY INDICATOR OF A POOR PROGNOSIS JAUNDICE FOR MORE THAN 7 DAYS BEFORE THE ONSET OF ENCEPHALOPATHY MOST SPONTANEOUS SURVIVORS HYPERACUTE CATEGORY OF ALF
  60. 60. ACUTE LIVER FAILURE PROGNOSIS PROGNOSTIC MODELS 1) KING’S COLLEGE HOSPITAL CRITERIA 2) THE CLICHY CRITERIA 3) THE MELD SCORE 4) SERUM BILIRUBIN, SERUM LACTATE, AND ETIOLOGY (GERMANY) 5) ACUTE LIVER FAILURE STUDY GROUP INDEX 6) THE APACHE II SCORE AND SEQUENTIAL ORGAN FAILURE ASSESSMENT (SOFA) INDEX
  61. 61. ACUTE LIVER FAILURE PROGNOSIS
  62. 62. LIVER TRANSPLANTATION LIVER TRANSPLANT IS ONE OF THE MAIN REASONS WHY SURVIVAL RATES FOR ALF HAVE INCREASED FROM LESS THAN 20% IN THE 1970S TO OVER 60% IN THE 2010S THE DECISION TO PROCEED WITH LIVER TRANSPLANTATION DEPENDS UPON THE PROBABILITY OF SPONTANEOUS HEPATIC RECOVERY
  63. 63. EXTRACORPOREAL LIVER SUPPORT ATTEMPTS TO IMPROVE SURVIVAL IN ALF USING EXTRACORPOREAL LIVER SUPPORT DEVICES EXTEND BACK TO THE 1970S 1. THE EXTRACORPOREAL LIVER ASSIST DEVICE (ELAD) SYSTEM, 2. BASED ON C3A HEPATOCYTES 3. THE BIOARTIFICIAL LIVER (BAL) BASED ON PORCINE HEPATOCYTES 4. MOLECULAR ADSORBENTS RECIRCULATING SYSTEM [MARS] 5. SINGLEPASS ALBUMIN DIALYSIS [SPAD] 6. CHARCOAL OR RESIN HEMOFILTRATION 7. PLASMAPHERESIS
  64. 64. ACUTE LIVER FAILURE DIAGNOSIS ACUTE LIVER FAILURE IS DIAGNOSED BY DEMONSTRATING ALL OF THE FOLLOWING: I. ELEVATED AMINOTRANSFERASES (often with abnormal bilirubin and alkaline phosphatase levels II. HEPATIC ENCEPHALOPATHY III.PROLONGED PROTHROMBIN TIME (INR ≥1.5)
  65. 65. THANKYOU
  66. 66. CASE • Managed with: • Hydration • N acetyl-cysteine Infusion • KCL drip • Lactulose enema • Meds: • Lactulose • KCL durule • Omeprazole • UDCA • Phospholipids • Rifaximin
  67. 67. CASE • Discharged with • Take home Meds: • Lactulose • KCL durule • Omeprazole • UDCA • Phospholipids
  68. 68. ACUTE LIVER FAILURE APPROACH TO MANAGEMENT OVERALL STRATEGY
  69. 69. ACUTE LIVER FAILURE DEFINITION

×