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{{Acute liver failure}}
{{Acute liver failure}}
{{CMG}}; {{AE}} {{ADI}}
{{CMG}} {{AE}} {{ADI}} {{HS}}
==Overview==
==Overview==
Liver transplantation remains the only definitive therapy in patients of acute liver failure who fail to regenerate liver tissue to maintain life. Whole organ liver transplantation (deceased liver) or living donor liver transplantation(LDLT) can also be opted.<ref name="pmid12484709">{{cite journal |author=Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, McCashland TM, Shakil AO, Hay JE, Hynan L, Crippin JS, Blei AT, Samuel G, Reisch J, Lee WM |title=Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States |journal=[[Annals of Internal Medicine]] |volume=137 |issue=12 |pages=947–54 |year=2002 |month=December |pmid=12484709 |doi= |url=http://www.annals.org/article.aspx?volume=137&page=947 |accessdate=2012-10-26}}</ref>
The candidates for liver transplantation should be identified as quickly as possible because the progression to multiorgan failure results in deterioration in many patients who are awaiting liver transplantation. While many people who develop acute liver failure recover with supportive treatment, liver transplantation is often required in people who continue to deteriorate or have poor prognostic factors. The patient's candidacy for liver transplantation should be assessed based on the patient's clinical scenario, as well as upon social and financial factors. Patient evaluation for liver transplantation should be done as soon as possible and before [[encephalopathy]] occurs. The key common feature among various prognostic evaluation systems is the presence of [[encephalopathy]]. Other common features are patient's age and severity of the liver injury which is assessed by [[coagulopathy]] or [[jaundice]]. To address the limitations, a wide variety of prognostic systems have been proposed but none has universal acceptance. King's college criteria is the most well-characterized evaluation system. Common absolute contraindications for liver transplantation include untreated [[sepsis]], uncontrolled extra-hepatobiliary infection, [[alcohol]] abuse, uncontrolled cardiopulmonary disease, [[cholangiocarcinoma]], metastatic malignancy to the liver and life-threatening systemic illness. Common postoperative complications for liver transplantation include infections, graft failure, vascular compromise, biliary stricture or stenosis, anastomosis leakage, [[thrombosis]] of [[hepatic artery]] and [[portal vein]] and depression.
==Surgery==
==Liver Transplantation==
* Drainage of [[ascites]]
* The candidates for liver transplantation should be identified as quickly as possible because the progression of multiorgan failure results in deterioration in many patients who are awaiting liver transplantation.<ref name="pmid18825677">{{cite journal| author=Ichai P, Samuel D| title=Etiology and prognosis of fulminant hepatitis in adults. | journal=Liver Transpl | year= 2008 | volume= 14 Suppl 2 | issue=  | pages= S67-79 | pmid=18825677 | doi=10.1002/lt.21612 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18825677  }} </ref><ref name="pmid22106945">{{cite journal| author=Craig DG, Bates CM, Davidson JS, Martin KG, Hayes PC, Simpson KJ| title=Staggered overdose pattern and delay to hospital presentation are associated with adverse outcomes following paracetamol-induced hepatotoxicity. | journal=Br J Clin Pharmacol | year= 2012 | volume= 73 | issue= 2 | pages= 285-94 | pmid=22106945 | doi=10.1111/j.1365-2125.2011.04067.x | pmc=3269587 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22106945  }} </ref>
* While many people who develop acute liver failure recover with supportive treatment, [[liver transplant]]ation is often required in people who continue to deteriorate or have adverse [[Prognosis|prognostic]] factors.
* While many people who develop acute liver failure recover with supportive treatment, [[liver transplant]]ation is often required in people who continue to deteriorate or have poor [[Prognosis|prognostic]] factors.
* "[[Liver dialysis]]" (various measures to replace normal liver function) is evolving as a treatment modality and is gradually being introduced in the care of patients with liver failure.
*The patient's candidacy for liver transplantation should be assessed based on the patient's clinical scenario, as well as upon social and financial factors. Patient evaluation for liver transplantation should be done as soon as possible and before [[encephalopathy]] occurs.<ref name="pmid12484709">{{cite journal |author=Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, McCashland TM, Shakil AO, Hay JE, Hynan L, Crippin JS, Blei AT, Samuel G, Reisch J, Lee WM |title=Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States |journal=[[Annals of Internal Medicine]] |volume=137 |issue=12 |pages=947–54 |year=2002 |month=December |pmid=12484709 |doi= |url=http://www.annals.org/article.aspx?volume=137&page=947 |accessdate=2012-10-26}}</ref>
===Liver Transplantation===
* The key common feature among various prognostic evaluation systems is the presence of encephalopathy. Other common features are patient's age and severity of the liver injury which is assessed by coagulopathy or jaundice. To address the limitations, a wide variety of prognostic systems have been proposed but none has universal acceptance. King's college criteria is the most well-characterized evaluation system.{{cite journal |vauthors=Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, McCashland TM, Shakil AO, Hay JE, Hynan L, Crippin JS, Blei AT, Samuel G, Reisch J, Lee WM |title=Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States |journal=Ann. Intern. Med. |volume=137 |issue=12 |pages=947–54 |year=2002 |pmid=12484709 |doi= |url=}}
The King's College criteria were described in a publication in 1989 by J.G. O'Grady and colleagues. The criteria were stratified into acetaminophen and non-acetaminophen causes of acute liver failure, due to the different operating characteristics of parameters correlating with prognosis in the two causes.
===King's College Criteria===
 
* The King’s College criteria are from O’Grady et al. The criteria were stratified into acetaminophen and non-acetaminophen causes of acute liver failure, due to the different mechanisms of damage correlating with prognosis in each of the causes.
{|style="padding:0.3em; float:center; margin-left:5px;border:1px solid #ffa508;"  
{| style="padding:0.3em; float:center; margin-left:5px;border:1px solid #ffa508;"  
|-style="background-color:#FFE4E1; align:center; color:#8B4513; text-align: center"
|- style="background-color:#FFE4E1; align:center; text-align: center"
|'''King's College Hospital criteria''' <br />
|'''King's College Hospital Criteria''' <br />
'''for liver transplantation in acute liver failure<ref>{{cite journal |author=O'Grady JG, Alexander GJ, Hayllar KM, Williams R |title=Early indicators of prognosis in fulminant hepatic failure |journal=Gastroenterology |volume=97 |issue=2 |pages=439-45 |year=1989 |pmid=2490426 |doi=}}</ref>'''
'''for Liver Transplantation in Acute Liver Failure<ref>{{cite journal |author=O'Grady JG, Alexander GJ, Hayllar KM, Williams R |title=Early indicators of prognosis in fulminant hepatic failure |journal=Gastroenterology |volume=97 |issue=2 |pages=439-45 |year=1989 |pmid=2490426 |doi=}}</ref>'''
|-
|-
|'''Patients with [[paracetamol]] toxicity'''<br />
|'''Acute Liver Failure with Acetaminophen Toxicity'''<br />
pH <7.3 or<br />  
*pH <7.3 or<br />  
[[Prothrombin time]] >100 seconds and<br /> [[serum creatinine]] level >3.4 mg/dL (>300 μmol/l)<br />
*[[Prothrombin time]] >100 seconds and<br /> [[Serum creatinine]] level >3.4 mg/dL (>300 μmol/l)<br />
if in grade III or IV [[hepatic encephalopathy|encephalopathy]]  
*Grade III or IV [[hepatic encephalopathy|encephalopathy]]  
|-
|-
|'''Other patients'''<br />
|'''Acute Liver Failure without Acetaminophen Toxicity'''<br />
Prothrombin time >100 seconds  or <br />
Prothrombin time >100 seconds  or <br />
''Three of the following variables'':<br />  
''Three of the following variables'':<br />  
*Age <10 yr or >40 yr  
*Age <10 yr or >40 yr  
*Cause:
*Cause:
** non-A, non-B hepatitis
** Non-A, non-B hepatitis
** [[halothane]] hepatitis
** [[Halothane]] hepatitis
** idiosyncratic drug reaction  
** Idiosyncratic drug reaction  
*Duration of jaundice before encephalopathy >7 days  
*Duration of jaundice before encephalopathy >7 days  
*prothrombin time >50 seconds
*Prothrombin time >50 seconds
*Serum [[bilirubin]] level >17.6 mg/dL (>300 μmol/l)  
*Serum [[bilirubin]] level >17.6 mg/dL (>300 μmol/l)  
|}
|}
===2011 AASLD Recommendations : Liver Transplantation <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)===
===Absolute contraindications for liver transplantation===
*Untreated sepsis
*Uncontrolled extrahepatobillary infection
*Alcohol abuse
*Uncontrolled cardiopulmonary disease
*Cholangiocarcinoma
*Metastatic malignancy to the liver
*Life-threatening systemic illness
===Relative contraindications for liver transplantation===
*Age >70
*Uncontrolled psychiatric disorder
*Intrahepatic sepsis
*HIV seropositivity with failure to control HIV viremia or CD4 <100/μL
*Severe malnutrition/wasting
*Portal vein thrombosis
*Renal failure not attributable to liver disease
*Severe hypoxemia secondary to right-to-left intrapulmonary shunts (Po2 <50 mmHg)
===Common complications for liver transplantation===
*Infections
**Bacterial: early, common postoperative infections
**Fungal/parasitic: late, opportunistic infections
**Viral: late, opportunistic infections, recurrent hepatitis
**Infections from donor
*Primary graft failure
*vascular compromise
*stricture, stenosis or leakage of the biliary anastomoses
*Recurrence of primary hepatic disorder
*Ischemic injury during harvesting
*Portal vein obstruction
*Hepatic artery thrombosis
*Difficult psychosocial adjustment
*Depression


{|class=wikitable
==References==
|-
{{Reflist|2}}
| style="text-align:center" | [[AASLD guidelines classification scheme#Classification of Recommendations|Class II-3]]
|-
|'''1.'''  Urgent hepatic transplantation is indicated in acute liver failure where prognostic indicators suggest a high likelihood of death.
|-
| '''2.''' Living donor or auxiliary liver transplantation may be considered in the setting of limited organ supply, but its use remains controversial.
|-
| '''3.''' Hepatic vein thrombosis with acute hepatic failure is an indication for liver transplantation, provided underlying malignancy is excluded.
|-
| '''4.''' Short-acting barbiturates and the induction of hypothermia to a core body temperature of 34-35 <sup>0</sup>�C may be considered for intracranial hypertension refractory to osmotic agents as a bridge to liver transplantation.
 
|}
 
{|class=wikitable
|-
| style="text-align:center" | [[AASLD guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|'''1.''' Contact with a transplant center and plans to transfer appropriate patients with ALF should be initiated early in the evaluation process.
|-
| '''2.''' Patients with acute liver failure secondary to mushroom poisoning should be listed for transplantation, as this procedure is often the only lifesaving option.
|-
| '''3.''' Patients with known or suspected herpes virus or varicella zoster as the cause of acute liver failure should be treated with acyclovir (5-10 mg/kg IV every 8 hours) and may be considered for transplantation.
|-
| '''4.''' Patients in whom Wilson disease is the likely cause of acute liver failure must be promptly considered for liver transplantation.
|-
| '''5.''' Patients with autoimmune hepatitis should be considered for transplantation even while corticosteroids are being administered.
|-
| '''6.'''  For acute fatty liver of pregnancy or the HELLP syndrome, expeditious delivery of the infant is recommended. Transplantation may need to be considered if hepatic failure does not resolve quickly following delivery.
|-
| '''7.''' Intracranial pressure monitoring is recommended in ALF patients with high grade hepatic encephalopathy, in centers with expertise in ICP monitoring, in patients awaiting and undergoing liver transplantation.


|}
[[Category:Hepatology]]
[[Category:Gastroenterology]]


==References==
{{reflist|2}}
{{WH}}
{{WH}}
{{WS}}
{{WS}}

Latest revision as of 21:24, 18 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2] Husnain Shaukat, M.D [3]

Overview

The candidates for liver transplantation should be identified as quickly as possible because the progression to multiorgan failure results in deterioration in many patients who are awaiting liver transplantation. While many people who develop acute liver failure recover with supportive treatment, liver transplantation is often required in people who continue to deteriorate or have poor prognostic factors. The patient's candidacy for liver transplantation should be assessed based on the patient's clinical scenario, as well as upon social and financial factors. Patient evaluation for liver transplantation should be done as soon as possible and before encephalopathy occurs. The key common feature among various prognostic evaluation systems is the presence of encephalopathy. Other common features are patient's age and severity of the liver injury which is assessed by coagulopathy or jaundice. To address the limitations, a wide variety of prognostic systems have been proposed but none has universal acceptance. King's college criteria is the most well-characterized evaluation system. Common absolute contraindications for liver transplantation include untreated sepsis, uncontrolled extra-hepatobiliary infection, alcohol abuse, uncontrolled cardiopulmonary disease, cholangiocarcinoma, metastatic malignancy to the liver and life-threatening systemic illness. Common postoperative complications for liver transplantation include infections, graft failure, vascular compromise, biliary stricture or stenosis, anastomosis leakage, thrombosis of hepatic artery and portal vein and depression.

Liver Transplantation

  • The candidates for liver transplantation should be identified as quickly as possible because the progression of multiorgan failure results in deterioration in many patients who are awaiting liver transplantation.[1][2]
  • While many people who develop acute liver failure recover with supportive treatment, liver transplantation is often required in people who continue to deteriorate or have poor prognostic factors.
  • The patient's candidacy for liver transplantation should be assessed based on the patient's clinical scenario, as well as upon social and financial factors. Patient evaluation for liver transplantation should be done as soon as possible and before encephalopathy occurs.[3]
  • The key common feature among various prognostic evaluation systems is the presence of encephalopathy. Other common features are patient's age and severity of the liver injury which is assessed by coagulopathy or jaundice. To address the limitations, a wide variety of prognostic systems have been proposed but none has universal acceptance. King's college criteria is the most well-characterized evaluation system.Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, McCashland TM, Shakil AO, Hay JE, Hynan L, Crippin JS, Blei AT, Samuel G, Reisch J, Lee WM (2002). "Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States". Ann. Intern. Med. 137 (12): 947–54. PMID 12484709.

King's College Criteria

  • The King’s College criteria are from O’Grady et al. The criteria were stratified into acetaminophen and non-acetaminophen causes of acute liver failure, due to the different mechanisms of damage correlating with prognosis in each of the causes.
King's College Hospital Criteria

for Liver Transplantation in Acute Liver Failure[4]

Acute Liver Failure with Acetaminophen Toxicity
Acute Liver Failure without Acetaminophen Toxicity

Prothrombin time >100 seconds or
Three of the following variables:

  • Age <10 yr or >40 yr
  • Cause:
    • Non-A, non-B hepatitis
    • Halothane hepatitis
    • Idiosyncratic drug reaction
  • Duration of jaundice before encephalopathy >7 days
  • Prothrombin time >50 seconds
  • Serum bilirubin level >17.6 mg/dL (>300 μmol/l)

Absolute contraindications for liver transplantation

  • Untreated sepsis
  • Uncontrolled extrahepatobillary infection
  • Alcohol abuse
  • Uncontrolled cardiopulmonary disease
  • Cholangiocarcinoma
  • Metastatic malignancy to the liver
  • Life-threatening systemic illness

Relative contraindications for liver transplantation

  • Age >70
  • Uncontrolled psychiatric disorder
  • Intrahepatic sepsis
  • HIV seropositivity with failure to control HIV viremia or CD4 <100/μL
  • Severe malnutrition/wasting
  • Portal vein thrombosis
  • Renal failure not attributable to liver disease
  • Severe hypoxemia secondary to right-to-left intrapulmonary shunts (Po2 <50 mmHg)

Common complications for liver transplantation

  • Infections
    • Bacterial: early, common postoperative infections
    • Fungal/parasitic: late, opportunistic infections
    • Viral: late, opportunistic infections, recurrent hepatitis
    • Infections from donor
  • Primary graft failure
  • vascular compromise
  • stricture, stenosis or leakage of the biliary anastomoses
  • Recurrence of primary hepatic disorder
  • Ischemic injury during harvesting
  • Portal vein obstruction
  • Hepatic artery thrombosis
  • Difficult psychosocial adjustment
  • Depression

References

  1. ↑ Ichai P, Samuel D (2008). "Etiology and prognosis of fulminant hepatitis in adults". Liver Transpl. 14 Suppl 2: S67–79. doi:10.1002/lt.21612. PMID 18825677.
  2. ↑ Craig DG, Bates CM, Davidson JS, Martin KG, Hayes PC, Simpson KJ (2012). "Staggered overdose pattern and delay to hospital presentation are associated with adverse outcomes following paracetamol-induced hepatotoxicity". Br J Clin Pharmacol. 73 (2): 285–94. doi:10.1111/j.1365-2125.2011.04067.x. PMC 3269587. PMID 22106945.
  3. ↑ Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, McCashland TM, Shakil AO, Hay JE, Hynan L, Crippin JS, Blei AT, Samuel G, Reisch J, Lee WM (2002). "Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States". Annals of Internal Medicine. 137 (12): 947–54. PMID 12484709. Retrieved 2012-10-26. Unknown parameter |month= ignored (help)
  4. ↑ O'Grady JG, Alexander GJ, Hayllar KM, Williams R (1989). "Early indicators of prognosis in fulminant hepatic failure". Gastroenterology. 97 (2): 439–45. PMID 2490426.

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