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Acute Liver Failure

Diagnosis :

AASLD guidelines :

Criteria for Diagnosis in Adults 
1. Jaundice < 26 weeks 
2.Coagulopathy (INR>1.5
3.Hepatic encephalopathy
4.No evidence of chronic liver disease.


  • Hemogram, RFT, LFT, INR, ECG
  • Monitoring of Blood sugars 
  • Arterial blood gas
  • Arterial ammonia  
  • Blood culture 
  • Workup for Malaria /Typhoid/Leptospira/Rickettsial infection-if  suspicion of ALF mimickers Routine Viral hepatitis serology,s
  • IgM anti HAV,HBsAg,anti-HBc ,IgM,anti HEV,anti HCV  
  • If Wilson suspected: Ceruloplasmin levels, KFRing/Urinary copper  
  • Brain imaging (CT/MRI) if there is a clinical suspicion 
  • Pregnancy test in females 
Severity assessment :

Poor clinical prognostic indicators  

  • Age >50 years 
  • Jaundice -encephalopathy interval >7 days 
  • Hepatic encephalopathy grade 3 & Higher 
  • Presence of cerebral oedema 
  • Creatinine >1.5mg/dl
Presence of any 3 ----indicates Poor prognosis 

Management :

  • ICU admission 
Supportive treatment 
  • Infection: Surveillance  & Prompt treatment 
  • Coagulopathy : (Although the role is  debatable )Injection Vit.K 10mg IV OD for 3 days  
  • Transfuse platelets/FFP for invasive procedures /active bleeding 
  • Injection PPI 20mg IV BD for stress ulcers 
  • Volume replacement 
  • Pressure support 

Disease-specific :

Grade I, II hepatic encephalopathy 
  • IV  -NAC: 150mg/kg in D5 over 15 min, 
  • then  50 mg/kg given over 4hrs  
  • followed by 100mg/kg over 16hrs  in patients 
Herpes virus or varicella-zoster: Acyclovir, 5-10mg/kgIV every 8hours 

HBV: Entecavir,0.5mg once daily through Ryles tube  

Autoimmune hepatitis: Prednisolone 40-60mg /day (With mild Hepatic encephalopathy) 

Acute fatty liver of Pregnancy: /HELLP syndrome: Prompt delivery 

Consider Liver transplantation 

Kings criteria for Liver transplantation :
The presence of one of the following should prompt a referral/transfer to a liver transplantation centre:

  • Acidosis (admission arterial pH < 7.30) OR
  • Hepatic encephalopathy (grade III or IV), AND coagulopathy (PT > 100 s), AND acute kidney injury (creatinine > 3.4 mg/dL), OR
  • Hyperlactatemia (4-hour lactate > 3.5 mmol/L, or 12-hour lactate > 3.0 mmol/L), OR
  • Hyperphosphatemia (48-96 hour phosphate > 3.7 mg/dL) in patients with acetaminophen-induced fulminant hepatic failure.