Acute Liver Failure

Key points

• Acute liver failure is the rapid onset of hepatocellular dysfunction (jaundice, coagulopathy, encephalopathy) with systemic complications, in a patient without pre-existing chronic liver disease.
• Causes: paracetamol overdose (commonest in the UK), viral hepatitis (A, B, E), drug reactions, acute fatty liver of pregnancy, Wilson's disease, Budd-Chiari syndrome, autoimmune hepatitis.
• Features: jaundice, coagulopathy (raised PT/INR - a key marker of severity), hepatic encephalopathy, hypoglycaemia; hyperacute cases risk cerebral oedema and raised ICP.
• Management: supportive ICU care; N-acetylcysteine (for paracetamol and also of benefit in non-paracetamol ALF); treat hypoglycaemia and raised ICP; do not routinely correct clotting unless there is bleeding or a procedure (PT/INR is prognostic).
• King's College Criteria identify the need for emergency liver transplantation. Paracetamol: arterial pH under 7.3, OR all three of PT over 100 s (INR over 6.5), creatinine over 300 micromol/L and grade 3-4 encephalopathy. Refer early to a transplant centre.