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Flashcards in FN: Liver Failure Deck (19):
1

Causes

Cirrhosis
Acute:
- 􏰁 Infection: Hep A/B, CMV, EBV, leptospirosis
- 􏰁 Toxin: EtOH, paracetamol, isoniazid, halothane 􏰁 - Vasc: Budd-Chiari
- 􏰁 Other: Wilson’s, AIH
- 􏰁 Obs: eclampsia, acute fatty liver of pregnancy

2

Signs

􏰀 1. Jaundice
􏰀 2. Oedema + ascites
􏰀 3. Bruising
􏰀4. Encephalopathy
􏰁 Aterixis
􏰁 Constructional apraxia (5-pointed star)
􏰀 5. Fetor hepaticus
6. Signs of cirrhosis / chronic liver disease

3

Ix

- Bloods
- Microbiology
- Radiology

4

Bloods required

1. FBC - infection, GI bleed, reduced MCV (EToH)
2. U&E
- reduced Urea, increased Creatinine: hepatorenal syndrome
- Urea synthesis in liver and therefore poor test of renal function
3. LFTs
- AST"ALT >2= EtOH
- AST: ALT <1 = Viral
- Albumin: reduced in chronic liver failure
- PT: increased in acute liver failure

4. Clotting: increased INR
5. Glucose
6. ABG: metabolic acidosis
7. Causes: Ferritin, alpha1 antitrypsin, caeruloplasmin, Abs, paracetamol levels

5

Microbiology

- hep, CMv, EBV serology
- Blood and urine culture
- Ascites MCS + SAAG

6

Radiology

CXR
Abdo Us + portal vein duplex

7

Hepatorenal syndrome

Renal failure in patients with advanced CLF
- Diagnosis of exclusions

8

Pathophysiology of hepatorenal syndrome

“Underfill theory”
􏰀 Cirrhosis → splanchnic arterial vasodilatation → effective circulatory volume → RAS activation → renal arterial vasoconstriction.
􏰀 Persistent underfilling of renal circulation → failure

9

Classification of hepatorenal syndrome

􏰀 Type 1: rapidly progressive deterioration (survival
<2wks)
􏰀 Type 2: steady deterioration (survival ~6mo)

10

Rx of Hepatorenal syndrome

􏰀 1. IV albumin + splanchnic vasoconstrictors (terlipressin)
􏰀 2. Haemodialysis as supportive Rx
􏰀 3. Liver Tx is Rx of choice

11

Mx of Liver Failure

􏰀 Manage in ITU
􏰀 Rx underlying cause: e.g. NAC in paracetamol OD 􏰀 Good nutrition: e.g. via NGT ̄c high carbs
􏰀 Thiamine supplements
􏰀 Prophylactic PPIs vs. stress ulcers

12

Monitoring of Liver Failure

􏰀 Fluids: urinary and central venous catheters 􏰀 Bloods: daily FBC, U+E, LFT, INR
􏰀 Glucose: 1-4hrly + 10% dextrose IV 1L/12h

13

Complications of Liver Failure

􏰀 1. Bleeding: Vit K, platelets, FFP, blood
􏰀 2. Sepsis: tazocin (avoid gent: nephrotoxicity)
􏰀3. Ascites: fluid and salt restrict, spiro, fruse, tap, daily wt 􏰀 4.Hypoglycaemia: regular BMs, IV glucose if <2mM
􏰀 5. Encephalopathy: avoid sedatives, lactulose ± enemas,
rifaximin
􏰀 6. Seizures: lorazepam
􏰀 Cerebral oedema: mannitol

14

Prescribing in Liver failure

􏰀 Avoid: opiates, oral hypoglycaemics, Na-containing IVI 􏰀 Warfarin effects ↑
􏰀 Hepatotoxic drugs: paracetamol, methotrexate,
isoniazid, salicylates, tetracycline

15

Poor prognostic factors

􏰀 - Grade 3/4 hepatic encephalopathy
- 􏰀 Age >40yrs
􏰀- Albumin <30g/L
- 􏰀 ↑INR
- 􏰀 Drug-induced liver failure

16

Lover Transplant types

􏰀 Cadaveric: heart-beating or non-heart beating
􏰀 Live: right lobe􏰀 Cadaveric: heart-beating or non-heart beating
􏰀 Live: right lobe

17

Criteria for paracetamol liver injry

Kings College Hospital Criteria in Acute Failure

18

Kings College Hospita criteria in paracetamol induced acute liver failure

pH< 7.3 24h after ingestion
Or all of:
PT > 100s
Cr > 300uM
Grade 3/4 encephalopathy

19

Kings college hospital criteria in non-paracetamol acute liver failure

PT > 100s

Or 3 out of 5 of:
Drug-induced
Age <10 or >40
>1wk from jaundice to encephalopathy
PT > 50s
BR ≥ 300uM

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