Qi:KT - Acute Liver Failure

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Have newly elevated LFTs and need to know if you should image that patient? Is there a role for NAC? Steroids? Join Drs Arnold and Wilson as they walk through the latest evidence in the management of Acute Liver Failure

Tentative QiKT Algorithm discussed in the podcast (pending final approval):

Tentative algorithm for management of acute liver failure - final will be available on tamingthesru.com/emergencyKT

Post and Algorithm by Colleen Arnold, MD and David Wilson, MD

Drs Arnold and Wilson are PGY-2 residents at the University of Cincinnati Emergency Medicine Program

Podcast and peer review by Saie Joshi, MD and Ryan LaFollette, MD

Dr Joshi is a PGY-2 resident at the University of Cincinnati Emergency Medicine Program. Dr. LaFollette is co-editor of TamingtheSRU.com

References

General Information:

  1. Polson J, Lee WM; American Association for the Study of Liver Disease. AASLD position paper: the management of acute liver failure. Hepatology. 2005 May;41(5):1179-97. doi: 10.1002/hep.20703. PMID: 15841455.

  2. European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu; Clinical practice guidelines panel; Wendon, J; Panel members; Cordoba J, Dhawan A, Larsen FS, Manns M, Samuel D, Simpson KJ, Yaron I; EASL Governing Board representative; Bernardi M. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol. 2017 May;66(5):1047-1081. doi: 10.1016/j.jhep.2016.12.003. PMID: 28417882.

  3. Flamm SL, Yang YX, Singh S, Falck-Ytter YT; AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute Guidelines for the Diagnosis and Management of Acute Liver Failure. Gastroenterology. 2017 Feb;152(3):644-647. doi: 10.1053/j.gastro.2016.12.026. Epub 2017 Jan 2. PMID: 28056348.

  4. Cross, Timothy, et al. “Acute liver failure.” Clinical Critical Care Medicine, 2006, pp. 531–542, https://doi.org/10.1016/b978-0-323-02844-8.50054-8.

  5. Shah NJ, Royer A, John S. Acute Liver Failure. [Updated 2023 Apr 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482374/

  6. Montrief, Tim. “Acute Liver Failure: Evidence-Based Evaluation and Management.” emDOCs.Net - Emergency Medicine Education, 26 Nov. 2018, www.emdocs.net/acute-liver-failure-evidence-based-evaluation-and-management/.

NAC:

  1. Jiang SX, Hussaini T, Yoshida EM. N-acetylcysteine for non-acetaminophen induced acute liver failure: A review. Saudi J Gastroenterol. 2022 Mar-Apr;28(2):85-91. doi: 10.4103/sjg.sjg_406_21. PMID: 35142656; PMCID: PMC9007071.

  2. Amjad W, Thuluvath P, Mansoor M, Dutta A, Ali F, Qureshi W. N-acetylcysteine in non-acetaminophen-induced acute liver failure: a systematic review and meta-analysis of prospective studies. Prz Gastroenterol. 2022;17(1):9-16. doi: 10.5114/pg.2021.107797. Epub 2021 Jul 14. PMID: 35371352; PMCID: PMC8942009.

  3. Walayat S, Shoaib H, Asghar M, Kim M, Dhillon S. Role of N-acetylcysteine in non-acetaminophen-related acute liver failure: an updated meta-analysis and systematic review. Ann Gastroenterol. 2021;34(2):235-240. doi: 10.20524/aog.2021.0571. Epub 2021 Jan 4. PMID: 33654365; PMCID: PMC7903568.

  4. Darweesh SK, Ibrahim MF, El-Tahawy MA. Effect of N-Acetylcysteine on Mortality and Liver Transplantation Rate in Non-Acetaminophen-Induced Acute Liver Failure: A Multicenter Study. Clin Drug Investig. 2017 May;37(5):473-482. doi: 10.1007/s40261-017-0505-4. PMID: 28205121.

  5. Lee WM, Hynan LS, Rossaro L, Fontana RJ, Stravitz RT, Larson AM, Davern TJ 2nd, Murray NG, McCashland T, Reisch JS, Robuck PR; Acute Liver Failure Study Group.

  6. Intravenous N-acetylcysteine improves transplant-free survival in early stage non-acetaminophen acute liver failure. Gastroenterology. 2009 Sep;137(3):856-64, 864.e1. doi: 10.1053/j.gastro.2009.06.006. Epub 2009 Jun 12. Erratum in: Gastroenterology. 2013 Sep;145(3):695. Dosage error in article text. PMID: 19524577; PMCID: PMC3189485.

  7. Singh S, Hynan LS, Lee WM; Acute Liver Failure Study Group. Improvements in hepatic serological biomarkers are associated with clinical benefit of intravenous N-acetylcysteine in early stage non-acetaminophen acute liver failure. Dig Dis Sci. 2013 May;58(5):1397-402. doi: 10.1007/s10620-012-2512-x. Epub 2013 Jan 17. PMID: 23325162; PMCID: PMC3663882.

Transplant:

  1. O'Grady JG, Alexander GJ, Hayllar KM, Williams R. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology. 1989 Aug;97(2):439-45. doi: 10.1016/0016-5085(89)90081-4. PMID: 2490426.

Hepatic Encephalopathy:

  1. Hoilat GJ, Ayas MF, Hoilat JN, Abu-Zaid A, Durer C, Durer S, Adhami T, John S. Polyethylene glycol versus lactulose in the treatment of hepatic encephalopathy: a systematic review and meta-analysis. BMJ Open Gastroenterol. 2021 May;8(1):e000648. doi: 10.1136/bmjgast-2021-000648. PMID: 34006606; PMCID: PMC8137169.

  2. Martí-Carvajal AJ, Gluud C, Arevalo-Rodriguez I, Martí-Amarista CE. Acetyl-L-carnitine for patients with hepatic encephalopathy. Cochrane Database Syst Rev. 2019 Jan 5;1(1):CD011451. doi: 10.1002/14651858.CD011451.pub2. PMID: 30610762; PMCID: PMC6353234.

  3. Acharya SK, Bhatia V, Sreenivas V, Khanal S, Panda SK. Efficacy of L-ornithine L-aspartate in acute liver failure: a double-blind, randomized, placebo-controlled study. Gastroenterology. 2009 Jun;136(7):2159-68. doi: 10.1053/j.gastro.2009.02.050. PMID: 19505424.

Coagulopathy:

  1. Pereira SP, Langley PG, Williams R. The management of abnormalities of hemostasis in acute liver failure. Semin Liver Dis. 1996 Nov;16(4):403-14. doi: 10.1055/s-2007-1007253. PMID: 9027953.

  2. Pereira SP, Rowbotham D, Fitt S, Shearer MJ, Wendon J, Williams R. Pharmacokinetics and efficacy of oral versus intravenous mixed-micellar phylloquinone (vitamin K1) in severe acute liver disease. J Hepatol. 2005 Mar;42(3):365-70. doi: 10.1016/j.jhep.2004.11.030. PMID: 15710219.

Steroids:

  1. Karkhanis, Jamuna, et al. “Steroid use in acute liver failure.” Hepatology, vol. 59, no. 2, 2013, pp. 612–621, https://doi.org/10.1002/hep.26678.

  2. Yeoman, Andrew D., et al. “Prognosis of acute severe autoimmune hepatitis (as-AIH): The role of corticosteroids in modifying outcome.” Journal of Hepatology, vol. 61, no. 4, 2014, pp. 876–882, https://doi.org/10.1016/j.jhep.2014.05.021.

  3. Potts, Jonathan R. “Optimizing management in autoimmune hepatitis with liver failure at initial presentation.” World Journal of Gastroenterology, vol. 17, no. 16, 2011, p. 2070, https://doi.org/10.3748/wjg.v17.i16.2070.

Imaging:

  1. Obaid Shakil, A., et al. Digestive Diseases and Sciences, vol. 45, no. 2, 2000, pp. 334–339, https://doi.org/10.1023/a:1005416727424.

  2. Romero, Miriam, et al. “Imaging appearance in acute liver failure: Correlation with clinical and pathology findings.” Digestive Diseases and Sciences, vol. 59, no. 8, 2014, pp. 1987–1995, https://doi.org/10.1007/s10620-014-3106-6.

  3. Gupta, Pankaj, et al. “Diagnostic accuracy of Doppler ultrasound, CT and MRI in Budd Chiari Syndrome: Systematic Review and meta-analysis.” The British Journal of Radiology, vol. 93, no. 1109, 2020, p. 20190847, https://doi.org/10.1259/bjr.20190847.