Key points in Critical Care Medicine

Pathophysiology, causes, and management of acute hepatic failure

“Adapted from Oxford Textbook of Critical Care”

Acute liver failure (ALF) is a rare, life-threatening clinical syndrome occurring in a person with no prior history of liver disease.
Acute liver failure (ALF) occurs in patients with acute hepatic necrosis resulting in hepatic encephalopathy, jaundice, and coagulopathy.
Acute liver failure is a multisystem disorder.
Viral hepatitis is the most common cause of ALF worldwide, with drug-induced liver failure the most common in the developed world.
ALF is a multi-system disorder resulting in encephalopathy, coagulopathy, systemic inflammatory response syndrome, and multi-organ failure.
Patients can be prothrombotic or have balanced coagulation disorders.
Several classifications exist incorporating time to encephalopathy from the onset of jaundice. O’Grady’s classification is the most widely used.
The management is initially supportive. Intravenous N-acetylcysteine is recommended for all patients.
Elective intubation is recommended for all patients who develop Grade III hepatic encephalopathy.
Liver transplantation is an appropriate and viable treatment for ALF. Early and safe transfer to a transplant centre for transplant assessment is advised.

Classification Time of onset jaundice to encephalopathy

Hyper acute 0-1 weeks

Acute 1-4 weeks

Subacute 4-26 weeks

Causes