Acute Liver Failure Management (AASLD 2023)

Algorithm Steps

1. ▶

   Start

   Suspected Acute Liver Failure

   INR ≥1.5 + encephalopathy + no prior liver disease + illness <26 weeks

   1. ●

      Action

      ICU Admission & Stabilization

      Immediate ICU care essential

      • Contact transplant center EARLY
      • Central line, arterial line
      • Avoid sedation if possible (mask encephalopathy)
      • Head of bed 30 degrees
      1. ●

         Action

         Determine Etiology

         Cause determines treatment and prognosis

         • Acetaminophen level (even if >24h)
         • Viral hepatitis panel (HAV, HBV, HEV)
         • Autoimmune markers (ANA, ASMA, IgG)
         • Wilson's disease (ceruloplasmin, 24h urine Cu)
         • Drug/toxin history
         • Pregnancy test (AFLP, HELLP)
         1. ◆

            Decision

            Grade of Hepatic Encephalopathy

            Assess West Haven criteria

            • Grade 1: Mild confusion, sleep disturbance
            • Grade 2: Drowsy, inappropriate behavior
            • Grade 3: Somnolent but arousable, confused
            • Grade 4: Coma, unresponsive
            1. ●

               Action

               Grade 1-2 HE

               Close monitoring, avoid precipitants

               • Lactulose to achieve 2-3 BM/day
               • Avoid sedatives/opioids
               • Correct metabolic derangements
               • Frequent neuro checks
               1. ◆

                  Decision

                  Transplant Evaluation

                  Apply King's College Criteria or other prognostic scores

                  • APAP: pH <7.3 OR (INR >6.5 + Cr >3.4 + Grade 3-4 HE)
                  • Non-APAP: INR >6.5 OR any 3 of: age <10 or >40, non-A/B hepatitis, drug toxicity, jaundice >7d before HE, INR >3.5, bilirubin >17.5
                  1. ●

                     Action

                     List for Transplant (Status 1A)

                     Poor prognosis criteria met

                     • UNOS Status 1A listing
                     • Continue supportive care
                     • Bridging therapies (plasmapheresis, MARS) if available
                     • Liver support devices if available
                     1. ✓

                        Outcome

                        Liver Transplantation

                        1-year survival ~80% post-transplant

                  2. ●

                     Action

                     Supportive Care & Monitoring

                     May recover with medical management

                     • Correct coagulopathy only if bleeding
                     • Avoid prophylactic FFP (masks prognosis)
                     • Glucose monitoring (hepatic gluconeogenesis impaired)
                     • Renal replacement therapy if needed
                     • Infection surveillance
                     1. ✓

                        Outcome

                        Spontaneous Recovery

                        ~40-50% of non-transplanted patients survive with supportive care

            2. ⚠

               Warning

               ⚠️ Grade 3-4 HE (High Risk)

               Risk of cerebral edema

               • Intubate for airway protection
               • Consider ICP monitoring
               • Mannitol 0.5-1 g/kg for ICP crisis
               • Hypertonic saline target Na 145-150
               • Avoid hyperthermia
      2. ◆

         Decision

         N-Acetylcysteine (NAC)

         Indicated for acetaminophen AND may benefit non-APAP ALF

         1. ●

            Action

            IV NAC Protocol

            21-hour IV protocol (preferred)

            • 150 mg/kg over 1 hour
            • 50 mg/kg over 4 hours
            • 100 mg/kg over 16 hours
            • Continue until INR <2 and encephalopathy resolving