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AGA issues guidelines for diagnosis, management of acute liver failure

The AGA has released new guideline recommendations for the diagnosis and management of acute liver failure that advise what tests should or should not be performed and which treatment systems should be implemented.

“ALF is a rare but significant problem with high morbidity and mortality,” Steven L. Flamm, MD, and colleagues wrote. “It is an uncommon disease process characterized by rapid progression and death. Liver transplantation, the ultimate treatment strategy, is necessary for some patients and requires significant resources and a lifetime of immunosuppression, yet other patients have had spontaneous resolution and no long-term issues.”

Flamm and colleagues developed 11 recommendations for pursuing ALF treatment using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

In patients presenting with ALF, their recommendations are as follows:

• Do not routinely test all patients for Wilson’s disease.
• Test for herpes simplex virus and treat patients with herpes simplex virus.
• Use MELD score rather than Kings College Criteria as a prognostic scoring system.
• Do not routinely use liver biopsy.
• Autoantibody testing should be performed.
• Do not empirically use treatments to reduce intracranial pressure.
• Extracorporeal artificial liver support systems should only be used within the context of a clinical trial.

Additionally, these special circumstances hold the following recommendations:

• In immunocompetent patients presenting with ALF, do not routinely test patients for varicella zoster virus.
• In pregnant women presenting with ALF, test for hepatitis E.
• In patients presenting with acetaminophen-associated ALF, use N-acetyl cysteine.
• In patients presenting with non–acetaminophen-associated ALF, N-acetyl cysteine should be used only in the context of clinical trials.

The researchers recognize that, despite the large number of published studies they reviewed, their recommendations fall into a category of low quality of evidence due to the poor available data and the balance of risks to benefits in certain strategies.

“Recognizing these and other limitations, the recommendations included here represent a rigorous, evidence-based summary of extensive literature describing the diagnosis and treatment of ALF and use of predictive models,” the researchers wrote. “Review of this guideline, plus the associated technical review, will facilitate effective shared decision making with ALF patients.” – by Talitha Bennett

Disclosure: The researchers report no relevant financial disclosures. All other disclosures were published with the report.