Acute Liver Failure for doctors – How it’s managed at King’s Liver ITU

Disclaimer: This article is not advice for patients and is intended as information for medical professionals only.

Acute liver failure with encephalopathy (toxic cognitive impairment) has a much worse outcome. Particularly if it comes on insidiously.

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Acute encephalopathy secondary to paracetamol for instance has a better outcome than that secondary to hepatitis or more chronic causes.

Paracetamol overdose is still by far the biggest cause of acute liver failure in the UK.

paracetamol

Resuscitation, early treatment with N-Acetylcysteine is key and involve ITU early.

Think about hypoglycaemia & hypovoleamia. Crystalloids with glucose and NAC are the mainstay of early management. Give antibiotics if you suspect at risk of infection and call the liver unit early if: history, consciousness, coagulopathy or any other adverse signs.

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There has been a dramatic improvement in outcomes as a result of the above. Survival is now over 75% of those going to King’s liver unit for acute liver failure.

Transplantation has led to massive improvements in the survival of those with previously a poor prognosis, but the medical management has also improved significantly even for those who cannot be transplanted.

This is in part due to earlier recognition. The average INR of those arriving at King’s has fallen from 6 to 3.5 over the past 15 years and rates of encephalopathy on arrival have improved greatly.

Cerebral oedema is an issue but it is becoming rarer due to early administration of NAC and resuscitation.

Some treatments such as cooling don’t seem to work. Plasma exchange might have a role in the future.

Transplantation particularly has a role in those where the cause is not clear / seronegative disease. Transplantation is not as effective in paracetamol overdose.

Prognostic criteria include: age, coagulopathy and encephalopathy. King’s have produced a new calculator to help distinguish between those who will/won’t benefit from transplant: New King’s Calculator.

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