New ACG guideline highlights treatment, transplant considerations for acute liver failure
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Key takeaways:
- Acute liver failure is “vastly different” from acute-on-chronic liver failure and decompensated cirrhosis.
- Clinicians should prioritize timely transfer to the transplant center a priority early in management.
The ACG has created a new clinical guideline based on existing data and expert opinion to aid clinicians in the diagnosis and management of patients with acute liver failure, with a focus on specific etiologies and disease presentation.
“Acute liver failure (ALF) is a life-threatening condition that occurs in patients with no preexisting liver disease and is characterized by liver injury, coagulopathy and hepatic encephalopathy,” Alexandra Shingina, MD, MSc, assistant professor of medicine in the division of gastroenterology, hepatology and nutrition at Vanderbilt University Medical Center, and colleagues wrote in the American Journal of Gastroenterology. “It has a multitude of etiologies and a variety of clinical presentations that can affect virtually every organ system. It is imperative for clinicians to recognize ALF early in patient presentation because initiation of treatment and transplant considerations could be lifesaving.”
Using the Grading of Recommendations Assessment, Development and Evaluation process, Shingina and colleagues reviewed existing scientific evidence and developed 10 clinical guidelines. In the absence of “robust evidence,” experts developed key concept statements, which summarized both expert opinion recommendations and definitions/epidemiological statements, and include guidance on general management, liver biopsy and management of specific causes of disease.
“Considering the variety of clinical presentations of ALF, individualization of care should be applied in specific clinical scenarios,” Shingina and colleagues noted.
Highlights of the guideline include:
- In patients with ALF and encephalopathy ( grade 2), early continuous renal replacement therapy is suggested for management of hyperammonemia, “even in the absence” of conventional renal replacement therapy indications.
- In the absence of active bleeding or an impending high-risk procedure, routine correction of coagulopathy is not recommended.
- Routine use of prophylactic antimicrobial agents is not recommended, as research has shown it did not improve the rate of bloodstream infection or 21-day mortality.
- In ALF patients with hypotension refractory to fluid resuscitation, norepinephrine is recommended as the first-line vasopressor; those who do not respond to norepinephrine should add vasopressin as a secondary agent.
- In patients with suspected N-acetyl-p-aminophenol (APAP) toxicity, early administration of N-acetylcysteine is recommended. However, in those with non-APAP ALF, the initiation of IV N-acetylcysteine is suggested.
- Antiviral therapy should be administered in patients with ALF due to hepatitis B virus reactivation.
- King’s College Criteria or MELD score is recommended for liver transplantation prognostication in patients with ALF. Those who meet the KCC criteria or who present with MELD score greater than 25 are at “high risk” for poor outcomes.
“ALF is a medical emergency and is potentially reversible if recognized and treated early,” Shingina and colleagues concluded. “ALF must be differentiated from acute-on-chronic liver failure and decompensated cirrhosis because management is vastly different. ALF affects multiple organs and carries high short-term mortality, making timely transfer to the transplant center a priority early on in patient management.”
They continued: “Patients at high risk of death have excellent prognosis after lifesaving LT.”
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