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Acute Liver Faliure Unit

Acute Liver Failure Unit is a dedicated unit offering comprehensive care to patients suffering from acute liver failure which is the development of sudden, severe hepatic dysfunction from an acute insult to the liver, associated with the onset of hepatic encephalopathy and coagulation abnormalities.

Our multidisciplinary team of highly qualified transplant surgeons, hepatologist, gastroenterologist, anaesthesiologist and other supporting staff works together to ensure quality care and successful recovery.  

Definition

Acute Liver Failure (ALF) is a rare disease caused due to loss of functioning of the liver associated with a high risk of mortality. It is usually common in people without pre-existing liver disease and causes rapid deterioration of liver function within days. Severe liver dysfunction caused due to acute liver failure (ALF) can result in multi-organ failure and even death. Patients suffering from ALF are managed at the advanced intensive care unit. Our team of expert doctors recognise the early signs of ALF and employ appropriate lifesaving interventions like liver transplantation.

The most widely accepted definition for the study of liver diseases is evidence of coagulation abnormality usually,

  • International Normalized Ratio (INR) ≥ 1.5
  • Neurological dysfunction with any degree of hepatic encephalopathy (mental alteration)
  • No prior evidence of liver diseases
  • Diseases course ≤ 26 Weeks

Classification

Based on the interval between the development of jaundice and the onset of encephalopathy, acute liver failure (ALF) is classified into 3 categories 

  • Hyperacute Liver Failure:  After the development of jaundice, the onset of encephalopathy is less than 7 days.
  • Acute Liver Failure: After the development of jaundice, the onset of encephalopathy is 8 to 28 days. 
  • Sub-Acute Liver Failure: After the development of jaundice, the onset of encephalopathy is more than 5 weeks but less than 12 weeks.
     

Aetiologies of ALF (What are the causes for ALF)

It is important to identify the aetiology of ALF for defining the treatment approach and prognosis. 

  • Acetaminophen-Induced Liver Injury
  • Drug-Induced Liver Injury (non-acetaminophen)
    • Antibiotics: amoxicillin-clavulanate, ciprofloxacin, nitrofurantoin, minocycline, dapsone, doxycycline, trimethoprim-sulfamethoxazole, efavirenz, didanosine, abacavir
    • Anti-epileptics: valproic acid, phenytoin, carbamazepine
    • Anti-tuberculosis drugs: isoniazid, rifampin-isoniazid, pyrazinamide
    • Herbs: ma huang, kava kava, Herbalife
    • Miscellaneous: propylthiouracil, amitriptyline, statins, amiodarone, methotrexate, methyldopa
    • NSAID(nonsteroidal anti-inflammatory drug): Diclofenac, ibuprofen, indomethacin, naproxen
  • Viral Hepatitis
    • CMV(cytomegalovirus), EBV (Epstein-Barr virus), herpes virus, varicella-zoster virus
    • Hepatitis A, B, C and E
  • Pregnancy Specific Liver Diseases
    • Acute fatty liver of pregnancy
    • HELLP (haemolysis, elevated liver enzymes, low palette count) syndrome
    • Preeclampsia-associated liver diseases
  • Ischemic Hepatitis
    • Budd-Chiari syndrome
    • Systemic hypotension
  • Reversible Causes
    • Autoimmune hepatitis
    • Leptospirosis, hepatic amoebiasis, malaria, rickettsial diseases
  • Miscellaneous
    • Malignant infiltration
    • Mushroom poisoning
    • Wilson's disease
       

Clinical Features

Based on the aetiology of ALF, the timing and indications of the clinical features of ALF may vary. The major indications of ALF range from simple symptoms to severe ones. These include

Simple symptoms

  • Abdominal pain
  • Fatigue
  • Malaise
  • Nausea 
  • Vomiting 

Severe symptoms

  • Hypotension
  • Sepsis
  • Hepatic encephalopathy (drowsiness, confusion, cognitive impairment, slowed mentation, and euphoria to deep coma)

With these symptoms, patients may also develop coagulation abnormalities (Prolonged PT/INR). This increases the risk of bleeding. However, due to further testing the chances to diagnose ALF may be delayed or even missed and the opportunity to provide definitive therapy is also lost. Therefore to make an early diagnosis of ALF, it is important to have a high index of suspicion.

The course of treatment for ALF is similar to that of multiple organ failure. The pathophysiology for ALF include

  • Loss of hepatocyte function
  • The release of toxins and cytokines

This is due to liver necrosis causing severe systemic inflammation and secondary bacterial infections from decreased immunity in ALF.
 

Management

In certain situations, the diagnosis of ALF may be delayed if a patient is experiencing minimal jaundice with altered mental status and absence of other features of ALF. Therefore, in such cases, it is necessary to have a high index of suspicion as early intervention. This is important to decrease morbidity and mortality.

The management of ALF must include:

  • Early identification of the aetiology of ALF and initiation of specific treatment is a must.
  • Symptomatic and supportive management of ALF (with an early transfer to the intensive care unit).
  • Discussion with liver transplant specialists must be held at the earliest and if required a patient must be immediately transferred to the liver transplant unit.
     

Liver Transplantation

With proper diagnosis and evaluation, our team of doctors make an early decision of whether or not a patient is a candidate for liver transplantation (LT). If a patient requires a liver transplant then early transfer to our state-of-the-art transplant unit is recommended to initiate simultaneous liver transplant evaluation and ALF management. Liver transplant has shown remarkable improvement in the condition of patients suffering from ALF. 

We at the unit perform liver transplant from both deceased (a person who is declared brain dead) donor and living (a relative or a living person who is a perfect match) donor with great success. We also perform auxiliary liver transplantation in which a patient’s own healthy part of the liver is left in place and the diseased part is replaced with a partial left or right lobe from the donor. Thereby, providing hepatic function until the native liver of the patient regenerates.
 

Summary

Since ALF is associated with significant morbidity and mortality. Therefore, we at unit promotes aggressive management of ALF and its complications. It has been observed that liver transplantation is the only life-saving modality in many patients with ALF. However, patients who are ineligible for transplant we offer plasma exchange therapy to improve their survival outcomes.

Our unit offers cutting edge technology that helps in early identification of ALF, as it is very important to decrease mortality.
 

Find Complete Relief from Nanavati Experts

If you think you are facing similar conditions, or have suffered from them in the past, please contact the Nanavati team to schedule an appointment at : +91 22 2626 7500

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