Acute liver failure surgery

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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]

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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.
• 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.

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

Acute Liver Failure with Acetaminophen Toxicity pH <7.3 or Prothrombin time >100 seconds and Serum creatinine level >3.4 mg/dL (>300 μmol/l) Grade III or IV encephalopathy

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)

2011 AASLD Recommendations for Acute Liver Failure (DO NOT EDIT)

Liver Transplantation (DO NOT EDIT)

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 0C may be considered for intracranial hypertension refractory to osmotic agents as a bridge to liver transplantation.

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.