Acute liver failure RPA Flashcards
What are key features of acute liver failure?
Severe acute liver injury (no underlying liver disease)
Liver injury AST/ALT >2-3x ULN
Impaired liver function (jaundice and coagulopathy)
Hepatic encephalopathy within 12 weeks of onset of jaundice
Aetiologies of ALF
Drugs - paracetamol (hyperacute), others are subacute - chemo, anti-TB drugs
Viral - hep B, A, E; less common CMV, HSV, VZV, dengue
Toxins - mushrooms, phosphorous
Wilsons disease
Autoimmune hepatitis
Lymphoma
Pregnancy
Budd-chiari
Management of ALF
Liaise +/- transfer to transplant unit
ICU Early intubation Early CRRT to protect cerebral circulation Antimicrobial prophylaxis Renal transplant Nutritional transplant Liver tranpslant
ALF is associated with what cerebral complication?
Intracranial hypertension –> oedema and coning
Which criteria is used for transplant suitability?
King’s college criteria
Different for paracetamol and non-paracetamol OD
Good for ruling people in rather than out
Decompensated cirrhosis severity scoring
Child Pugh score - tells you whether its compensated or decompensated (≥7) and associated survival
Ascites Encephalopathy Bilirubin Serum albumin INR
What’s the MELD score?
In the context of transplant and how to prioritise
Higher the MELD score, higher the mortality, and quicker you need to transplant (>35 you are eligible for the next organ that comes up)
Creatinine
Bili
INR
What does decompensated cirrhosis mean?
Variceal bleeding
Ascites
Hepatic encephalopathy
What’s acute on chronic liver failure (ACLF)?
Acute liver failure in the context of chronic liver disease
At risk of multiple organ failures - liver, kidney, brain, coagulation, circulation, respiratory
Much higher and earlier mortality than decompensated cirrhosis due to multiorgan failure
Management of cirrhotic ascites
Salt restriction
Spironolactone 100mg, increasing to 400mg/day +/- frusemide 40mg increasing to 160mg/day
Aim 1kg weight loss/day
DO NOT USE FRUSEMIDE ALONE
AVOID THIAZIDE DIURETICS
TIPSS in recurrent ascites (join hepatic vein and portal vein)
Hepatorenal syndrome
How is it classified?
HRS-AKI
HRS-non-AKI
- HRS-AKD + HRS-CKD
Hepatorenal syndrome Rx
Terlipressin (vasoconstrictor) first line
Albumin
Hyponatraemia in cirrhosis
Most will have hypervolaemic hyponatraemia
Na 110-130 Stop diuretics Correct hypokalaemia FR 1-1.5L Consider conc albumin if above doesn't work
Na <110
ICU management
Occasionally use hypertonic saline
Effects of albumin in chronic decompensated liver disease
In the outpatient setting
ANSWER trial
Reduces mortality
Reduces need for paracentesis
Reduces incidence of refractory ascites
Prevention of bleeding oesophageal varices
Primary prevention
Beta blocker** 1st line, more effective than banding
OR
Banding
Secondary prevention Banding + beta blockers Early TIPSS for child pugh B with ongoing bleeding or C (within 72 hours) - not done often in the real world but should be Surgical shunt Liver transplant
