Urgent management of liver failure is challenging, and the first few days can make a major difference in the prognosis. An AASLD symposium at DDW^® on Monday, May 20, examined the management options for the first 48 hours of patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF).

R. Todd Stravitz, MD, FACP, FACG, FAASLD, of Virginia Commonwealth University, Richmond, who discussed the urgent management of ALF within the first 48 hours, noted that the first hour is possibly the most critical.

“The first hour is the data assembly and the initiation of therapy hour,” Dr. Stravitz said. “The first things I ask myself are why this patient is jaundiced and confused, what caused this patient’s liver injury and how severe is it, because this potentially initiates the liver transplant cascade and the decision to either transfer to a liver transplant program or the activation of an in-house liver transplant team.”

The initial evaluation can be challenging, he said, because there is a differential diagnosis of acute liver failure. He cited a recent paper published by investigators at Northwestern University who reviewed 300 cases of acute liver failure from the ALF Study Group and found that a significant number of patients were misdiagnosed as having ALF when, in fact, they actually had alcoholic hepatitis or ACLF.

“Once the diagnosis is made, the first 24 hours are important because you need to assess whether systemic complications of ALF will start and how these systemic complications can be avoided,” Dr. Stravitz said. “The next 24 hours are about the management of complications as necessary. Finally, at 48 hours, you’re deciding whether this patient should go to the operating room or should the transplant team be stopped.”

The answer is not always “yes,” he said.

“The transplant train in patients with acute liver failure is very hard to stop,” Dr. Stravitz said. “There are some warning signs; however, where a patient is on the way to the operating room and probably should not be.”

Those warning signs, he said, include hemodynamic instability, prolonged intracranial hypertension, prolonged low cerebral perfusion pressure, concerning neurological findings and head CT evidence of brainstem herniation.

Jasmohan S. Bajaj, MD, AGAF, FACG, FAASLD, FRCP, of Virginia Commonwealth University and McGuire VA Medical Center, Richmond, followed with a discussion of the urgent management of ACLF within the first 48 hours.

As with ALF, Dr. Bajaj said the initial evaluation and diagnosis of ACLF is crucial.

“It’s important to remember that ACLF is not a static thing,” he said. “Patients can come in and out of ACLF, so just because they don’t have it at admission, you need to be very careful about whether this patient is going to develop it over the next 48 hours.”

In most Western countries, Dr. Bajaj said that ACLF begins on the background of compensated and decompensated cirrhosis; however, he noted that chronic liver disease is also considered a background for ACLF.

“Infections are a major cause of ACLF in Western countries and prompt, flexible and appropriate response is required,” he said. “Focusing on appropriate therapies for drug-resistant organisms is essential to prevent the cascade of organ failures. Liver support devices are evolving but as of yet there are no clear guidelines for their use in ACLF.”