Acute liver failure laboratory findings: Difference between revisions

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__NOTOC__
__NOTOC__
{{Acute liver failure}}
{{Acute liver failure}}
{{CMG}}
{{CMG}} {{AE}} {{HS}}
 
==Overview==
==Overview==
All patients with clinical or laboratory evidence of moderate to severe acute hepatitis should have immediate measurement of prothrombin time and careful evaluation of mental status. If the prothrombin time is prolonged by ≈ 4-6 seconds or more (INR ≥1.5)
Acute liver failure can present with nonspecific symptoms and it occurs in healthy individuals without a previous history of liver disease. So, the initial labs in the acute liver failure are planned to evaluate both the etiology and the severity of the disease. All patients with clinical or laboratory evidence of moderate to severe acute [[hepatitis]] should have an immediate measurement of [[prothrombin time]] and careful evaluation of [[mental status]]. If the [[prothrombin time]] is prolonged (INR ≥1.5) and there is any evidence of altered [[sensorium]], the diagnosis of acute liver failure should be strongly suspected and hospital admission is mandatory.
and there is any evidence of altered [[sensorium]], the diagnosis of ALF should be strongly suspected and hospital admission is mandatory<ref name="Polson">{{cite journal |author=Polson J, Lee WM |title=AASLD position paper: the management of acute liver failure |journal=Hepatology |volume=41 |issue=5 |pages=1179-97 |year=2005 |pmid=15841455 |doi=10.1002/hep.20703}}</ref>.
 
==Laboratory Findings==
==Laboratory Findings==
Initial laboratory examination must be extensive in order to evaluate both the aetiology and severity.  
* Acute liver failure can present with nonspecific symptoms and it occurs in healthy individuals without a previous history of liver disease. So, the initial labs in the acute liver failure are planned to evaluate both the etiology and the severity of the disease.<ref name="Polson">{{cite journal |author=Polson J, Lee WM |title=AASLD position paper: the management of acute liver failure |journal=Hepatology |volume=41 |issue=5 |pages=1179-97 |year=2005 |pmid=15841455 |doi=10.1002/hep.20703}}</ref><ref name="pmid16775039">{{cite journal| author=Wasley A, Fiore A, Bell BP| title=Hepatitis A in the era of vaccination. | journal=Epidemiol Rev | year= 2006 | volume= 28 | issue=  | pages= 101-11 | pmid=16775039 | doi=10.1093/epirev/mxj012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16775039  }} </ref><ref name="pmid12753342">{{cite journal |vauthors=Khuroo MS, Kamili S |title=Aetiology and prognostic factors in acute liver failure in India |journal=J. Viral Hepat. |volume=10 |issue=3 |pages=224–31 |year=2003 |pmid=12753342 |doi= |url=}}</ref><ref name="pmid22271089">{{cite journal| author=Torres HA, Davila M| title=Reactivation of hepatitis B virus and hepatitis C virus in patients with cancer. | journal=Nat Rev Clin Oncol | year= 2012 | volume= 9 | issue= 3 | pages= 156-66 | pmid=22271089 | doi=10.1038/nrclinonc.2012.1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22271089  }} </ref>
 
{| class="wikitable"
;Initial laboratory analysis<ref name="Polson"/>
! colspan="1" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" + |LAB
*[[Prothrombin time]]/INR
! colspan="1" rowspan="1" align="center" style="background:#4479BA; color: #FFFFFF;" + |values in Acute liver failure
*[[Complete blood count]]
!Comments
*Chemistries
|-
**Liver function test: [[Aspartate transaminase|AST]], [[Alanine transaminase|ALT]], [[alkaline phosphatase]], [[Gamma-glutamyl transpeptidase|GGT]], total [[bilirubin]], [[albumin]]
| align="center" style="background:#DCDCDC;" + |
**[[Creatinine]], urea/[[blood urea nitrogen]], sodium, potassium, chloride, bicarbonate, calcium, magnesium, phosphate
* [[Prothrombin time]]/[[INR]]
**[[Blood sugar|glucose]]
|
**[[Amylase]] and [[lipase]]
* Increased
*[[Arterial blood gas]], [[lactate]]
|
*Blood type and screen
* Prolonged [[prothrombin time]], resulting in an INR ≥1.5; it shows [[coagulopathy]] which is a part of acute liver failure criteria.
*[[Paracetamol]] (Acetaminophen) level, Toxicology screen
|-
*[[Viral hepatitis]] serologies: anti-HAV IgM, HBSAg, anti-HBc IgM, anti-HEV  
| align="center" style="background:#DCDCDC;" + |
*[[Hemoglobin]]  
|
* Low
|
* [[Anemia]] may be present
|-
| colspan="1" rowspan="1" align="center" style="background:#DCDCDC;" + |
**[[Liver function tests]] ([[Aspartate transaminase|AST]], [[Alanine transaminase|ALT]], [[alkaline phosphatase]], [[Gamma-glutamyl transpeptidase|GGT]])
| colspan="1" rowspan="1" |
* Elevated
|
* [[Liver enzymes]] are elevated in acute liver failure. The decrease in liver enzymes may indicate recovery or worsening of liver failure and an indication of hepatic mass loss.
|-
|
* Total [[bilirubin]]  
|
* Elevated
|
* [[Bilirubin]] and [[INR|PT/INR]] will continue to rise in liver failure but if a patient is improving, bilirubin and PT/INT will also improve.
|-
|
* [[Albumin]]
|
* Low
|
* [[Albumin]] indicates the synthetic function of the liver.
|-
| colspan="1" rowspan="1" align="center" style="background:#DCDCDC;" + |
**[[Blood sugar|Blood glucose]]
| colspan="1" rowspan="1" |
* Low
|
* Decrease hepatic [[glycogenolysis]] and [[gluconeogenesis]]
|-
|
* [[Blood urea nitrogen|BUN and CR]]
|
* Elevated
|
* Decrease clearance in [[hepatorenal syndrome]]
|-
| align="center" style="background:#DCDCDC;" + |
*Toxicology screen ([[Acetaminophen|acetaminophen level]]) and blood alcohol level
|
|
* Detectable in [[acetaminophen]] poisioning
|-
| align="center" style="background:#DCDCDC;" + |
*[[Viral hepatitis]] markers: anti-HAV IgM, HBSAg, anti-HBc IgM, anti-HEV
|
* Dectectable in viral hepatitis
|
* Viral serology and [[PCR]] can detect the viral agent
|-
|
*[[Autoimmune]] markers: [[Anti-nuclear antibody|ANA]], [[Anti-actin antibodies|ASMA]], LKMA, [[Antibody|Immunoglobulin]] levels
*[[Autoimmune]] markers: [[Anti-nuclear antibody|ANA]], [[Anti-actin antibodies|ASMA]], LKMA, [[Antibody|Immunoglobulin]] levels
*[[Ceruloplasmin]] Level ( when Wilson's disease suspected)
|
*[[Pregnancy test]] (females)
* Detectable in auto immune hepatitis.
*[[Ammonia]] (arterial if possible)
|
*[[HIV]] status (has implication for [[transplantation]])
* Antibody screen can detect antibodies associated with [[autoimmune hepatitis]] such as [[anti-smooth muscle antibody]] or [[ANA]].
===Liver Biopsy===
A [[liver biopsy]] done via the [[jugular|transjugular]] route because of [[coagulopathy]] is not usually necessary other than in occasional malignancies.
 
As the evaluation continues, several important decisions have to be made such as whether to admit the patient to an ICU, or whether to transfer the patient to a transplant facility. Consultation with the transplant centre as early as possible is critical due to possibility of rapid progression of ALF.
====2011 AASLD Recommendations : General Measures <ref name="urlwww.aasld.org">{{cite web |url=http://www.aasld.org/practiceguidelines/Documents/AcuteLiverFailureUpdate2011.pdf |title=www.aasld.org |format= |work= |accessdate=2012-10-26}}</ref>(DO NOT EDIT)====
 
{|class=wikitable
|-
| style="text-align:center" | [[AASLD guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|-
| '''1.''' Liver biopsy is recommended when autoimmune hepatitis is suspected as the cause of acute liver failure, and autoantibodies are negative.
|
*[[Ceruloplasmin]] Level
|
|
* Elevated in [[Wilson's disease|wilson's]] disease
|-
|-
| '''2.''' In patients with acute liver failure who have a previous cancer history or massive hepatomegaly, consider underlying malignancy and obtain imaging and liver biopsy to confirm or exclude the diagnosis.
|
*[[Lactate|Blood lactate]]
|
* Elevated
|
* Blood [[lactate]] is elevated due to decrease [[hepatic]] clearance and [[ischemia]] to hepatic tissue
|-
|-
| '''3.''' If the etiological diagnosis remains elusive after extensive initial evaluation, liver biopsy may be appropriate to attempt to identify a specific etiology that might influence treatment strategy.
|
 
*[[Ammonia|Ammonia levels]]
|
* Elevated
|
* Decrease [[ammonia]] clearance
|}
|}


==References==
==References==
{{reflist|2}}
{{Reflist|2}}
 
[[Category:Hepatology]]
[[Category:Gastroenterology]]
 
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Organ failure]]
[[Category:Causes of death]]
[[Category:Hepatology]]
[[Category:Gastroenterology]]
[[Category:Intensive care medicine]]

Latest revision as of 22:20, 1 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2]

Overview

Acute liver failure can present with nonspecific symptoms and it occurs in healthy individuals without a previous history of liver disease. So, the initial labs in the acute liver failure are planned to evaluate both the etiology and the severity of the disease. All patients with clinical or laboratory evidence of moderate to severe acute hepatitis should have an immediate measurement of prothrombin time and careful evaluation of mental status. If the prothrombin time is prolonged (INR ≥1.5) and there is any evidence of altered sensorium, the diagnosis of acute liver failure should be strongly suspected and hospital admission is mandatory.

Laboratory Findings

  • Acute liver failure can present with nonspecific symptoms and it occurs in healthy individuals without a previous history of liver disease. So, the initial labs in the acute liver failure are planned to evaluate both the etiology and the severity of the disease.[1][2][3][4]
LAB values in Acute liver failure Comments
  • Increased
  • Low
  • Elevated
  • Liver enzymes are elevated in acute liver failure. The decrease in liver enzymes may indicate recovery or worsening of liver failure and an indication of hepatic mass loss.
  • Elevated
  • Bilirubin and PT/INR will continue to rise in liver failure but if a patient is improving, bilirubin and PT/INT will also improve.
  • Low
  • Albumin indicates the synthetic function of the liver.
  • Low
  • Elevated
  • Dectectable in viral hepatitis
  • Viral serology and PCR can detect the viral agent
  • Detectable in auto immune hepatitis.
  • Elevated
  • Elevated

References

  1. ↑ Polson J, Lee WM (2005). "AASLD position paper: the management of acute liver failure". Hepatology. 41 (5): 1179–97. doi:10.1002/hep.20703. PMID 15841455.
  2. ↑ Wasley A, Fiore A, Bell BP (2006). "Hepatitis A in the era of vaccination". Epidemiol Rev. 28: 101–11. doi:10.1093/epirev/mxj012. PMID 16775039.
  3. ↑ Khuroo MS, Kamili S (2003). "Aetiology and prognostic factors in acute liver failure in India". J. Viral Hepat. 10 (3): 224–31. PMID 12753342.
  4. ↑ Torres HA, Davila M (2012). "Reactivation of hepatitis B virus and hepatitis C virus in patients with cancer". Nat Rev Clin Oncol. 9 (3): 156–66. doi:10.1038/nrclinonc.2012.1. PMID 22271089.

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