Indian Journal of Critical Care Medicine

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 19 , ISSUE 1 ( 2015 ) > List of Articles


Recent advances in management of acute liver failure

Sunil Mathai, Charles Panackel, Rony Thomas, Benoy Sebastian

Keywords : Acute liver failure, fulminant liver failure, hepatocyte transplantation liver assist devices, liver transplantation, molecular adsorbents recirculation system

Citation Information : Mathai S, Panackel C, Thomas R, Sebastian B. Recent advances in management of acute liver failure. Indian J Crit Care Med 2015; 19 (1):27-33.

DOI: 10.4103/0972-5229.148636

License: CC BY-ND 3.0

Published Online: 01-12-2015

Copyright Statement:  Copyright © 2015; The Author(s).


Acute liver failure (ALF) is a life-threatening illness, where a previously normal liver fails within days to weeks. Sudden loss of synthetic and detoxification function of liver results in jaundice, encephalopathy, coagulopathy, and multiorgan failure. The etiology of ALF varies demographically. The mortality of ALF is as high as 40-50%. The initial care of patients with ALF depends on prompt recognition of the condition and early detection of etiology. Management includes intensive care support, treatment of specific etiology if present and early detection of candidates for liver transplantation. Liver transplantation remains the only therapeutic intervention with proven survival benefit in patients with irreversible ALF. Living related liver transplantation, auxiliary liver transplantation, and  ABO-incompatible liver transplantation are coming up in a big way. Liver assist devices and hepatocyte transplant remain experimental and further advances are required. Public health measures to control hepatitis A, B, E, and drug-induced liver injury will reduce the incidence and mortality of ALF.

PDF Share
  1. Bernal W, Wendon J. Acute liver failure. N Engl J Med 2013;369:2525-34.
  2. Lee WM. Acute liver failure. Semin Respir Crit Care Med 2012;33:36-45.
  3. Bower WA, Johns M, Margolis HS, Williams IT, Bell BP. Population-based surveillance for acute liver failure. Am J Gastroenterol 2007;102:2459-63.
  4. Khuroo MS, Kamili S. Aetiology and prognostic factors in acute liver failure in India. J Viral Hepat 2003;10:224-31.
  5. Acharya SK, Dasarathy S, Kumer TL, Sushma S, Prasanna KS, Tandon A, et al. Fulminant hepatitis in a tropical population: Clinical course, cause, and early predictors of outcome. Hepatology 1996;23:1448-55.
  6. Trey C, Davidson CS. The management of fulminant hepatic failure. Prog Liver Dis 1970;3:282-98.
  7. O′Grady JG, Schalm SW, Williams R. Acute liver failure: Redefining the syndromes. Lancet 1993;342:273-5.
  8. Polson J, Lee WM, American association for the study of liver disease. AASLD position paper: The management of acute liver failure. Hepatology 2005;41:1179-97.
  9. Bernal W, Auzinger G, Dhawan A, Wendon J. Acute liver failure. Lancet 2010;376:190-201.
  10. Larson AM. Diagnosis and management of acute liver failure. Curr Opin Gastroenterol 2010;26:214-21.
  11. Ichai P, Samuel D. Etiology and prognosis of fulminant hepatitis in adults. Liver Transpl 2008;14 Suppl 2:S67-79.
  12. Willner IR, Uhl MD, Howard SC, Williams EQ, Riely CA, Waters B. Serious hepatitis A: An analysis of patients hospitalized during an urban epidemic in the United States. Ann Intern Med 1998;128:111-4.
  13. Vento S, Garofano T, Renzini C, Cainelli F, Casali F, Ghironzi G, et al. Fulminant hepatitis associated with hepatitis A virus superinfection in patients with chronic hepatitis C. N Engl J Med 1998;338:286-90.
  14. Dalton HR, Bendall R, Ijaz S, Banks M. Hepatitis E: An emerging infection in developed countries. Lancet Infect Dis 2008;8:698-709.
  15. Yeo W, Zee B, Zhong S, Chan PK, Wong WL, Ho WM, et al. Comprehensive analysis of risk factors associating with Hepatitis B virus (HBV) reactivation in cancer patients undergoing cytotoxic chemotherapy. Br J Cancer 2004;90:1306-11.
  16. Reuben A, Koch DG, Lee WM, Acute Liver Failure Study Group. Drug-induced acute liver failure: Results of a U.S. multicenter, prospective study. Hepatology 2010;52:2065-76.
  17. Larson AM, Polson J, Fontana RJ, Davern TJ, Lalani E, Hynan LS, et al. Acetaminophen-induced acute liver failure: Results of a United States multicenter, prospective study. Hepatology 2005;42:1364-72.
  18. Chalasani N, Fontana RJ, Bonkovsky HL, Watkins PB, Davern T, Serrano J, et al. Causes, clinical features, and outcomes from a prospective study of drug-induced liver injury in the United States. Gastroenterology 2008;135:1924-34.e1.
  19. Björnsson E, Olsson R. Outcome and prognostic markers in severe drug-induced liver disease. Hepatology 2005;42:481-9.
  20. Korman JD, Volenberg I, Balko J, Webster J, Schiodt FV, Squires RH Jr, et al. Screening for Wilson disease in acute liver failure: A comparison of currently available diagnostic tests. Hepatology 2008;48:1167-74.
  21. Joshi D, James A, Quaglia A, Westbrook RH, Heneghan MA. Liver disease in pregnancy. Lancet 2010;375:594-605.
  22. Birrer R, Takuda Y, Takara T. Hypoxic hepatopathy: Pathophysiology and prognosis. Intern Med 2007;46:1063-70.
  23. Stravitz RT, Lefkowitch JH, Fontana RJ, Gershwin ME, Leung PS, Sterling RK, et al. Autoimmune acute liver failure: Proposed clinical and histological criteria. Hepatology 2011;53:517-26.
  24. Escudié L, Francoz C, Vinel JP, Moucari R, Cournot M, Paradis V, et al. Amanita phalloides poisoning: Reassessment of prognostic factors and indications for emergency liver transplantation. J Hepatol 2007;46:466-73.
  25. Stravitz RT, Kramer AH, Davern T, Shaikh AO, Caldwell SH, Mehta RL, et al. Intensive care of patients with acute liver failure: Recommendations of the U.S. acute liver failure study group. Crit Care Med 2007;35:2498-508.
  26. Fontana RJ. Acute liver failure. In: Sleisenger MH, Fordtran JS, editors. Gastrointestinal Disease: Pathophysiology, Diagnosis, and Management. 10 th ed. Philadelphia: Saunders; 2010.
  27. Deepak NA, Patel ND. Differential diagnosis of acute liver failure in India. Ann Hepatol 2006;5:150-6.
  28. Smilkstein MJ, Knapp GL, Kulig KW, Rumack BH. Efficacy of oral N-acetylcysteine in the treatment of acetaminophen overdose. Analysis of the national multicenter study (1976-1985). N Engl J Med 1988;319:1557-62.
  29. Lee WM, Hynan LS, Rossaro L, Fontana RJ, Stravitz RT, Larson AM, et al. Intravenous N-acetylcysteine improves transplant-free survival in early stage non-acetaminophen acute liver failure. Gastroenterology 2009;137:856-64.e1.
  30. Czaja AJ. Corticosteroids or not in severe acute or fulminant autoimmune hepatitis: Therapeutic brinksmanship and the point beyond salvation. Liver Transpl 2007;13:953-5.
  31. Miyake Y, Iwasaki Y, Takaki A, Fujioka S, Takaguchi K, Ikeda H, et al. Lamivudine treatment improves the prognosis of fulminant hepatitis B. Intern Med 2008;47:1293-9.
  32. Scott TR, Kronsten VT, Hughes RD, Shawcross DL. Pathophysiology of cerebral oedema in acute liver failure. World J Gastroenterol 2013;19:9240-55.
  33. Wang DW, Yin YM, Yao YM. Advances in the management of acute liver failure. World J Gastroenterol 2013;19:7069-77.
  34. Pyleris E, Giannikopoulos G, Dabos K. Pathophysiology and management of acute liver failure. Ann Gastroenterol 2010;23:257-65.
  35. Shawcross DL, Wendon JA. The neurological manifestations of acute liver failure. Neurochem Int 2012;60:662-71.
  36. Vaquero J, Fontana RJ, Larson AM, Bass NM, Davern TJ, Shakil AO, et al. Complications and use of intracranial pressure monitoring in patients with acute liver failure and severe encephalopathy. Liver Transpl 2005;11:1581-9.
  37. Larsen FS, Murphy N, Bernal WL. Prophylactic effect of mild hypothermia to prevent brain edema in patients with acute liver failure: Results of a multicenter, randomized, controlled trial. J Hepatol 2011;54:S26.
  38. Siniscalchi A, Dante A, Spedicato S, Riganello L, Zanoni A, Cimatti M, et al. Hyperdynamic circulation in acute liver failure: Reperfusion syndrome and outcome following liver transplantation. Transplant Proc 2010;42:1197-9.
  39. Lee WM, Stravitz RT, Larson AM. Introduction to the revised American Association for the Study of Liver Diseases Position Paper on acute liver failure 2011. Hepatology 2012;55:965-7.
  40. Wang DW, Yin YM, Yao YM. Advances in the management of acute liver failure. World J Gastroenterol 2013;19:7069-77.
  41. Davenport A. Continuous renal replacement therapies in patients with liver disease. Semin Dial 2009;22:169-72.
  42. Leber B, Spindelboeck W, Stadlbauer V. Infectious complications of acute and chronic liver disease. Semin Respir Crit Care Med 2012;33:80-95.
  43. Agarwal B, Wright G, Gatt A, Riddell A, Vemala V, Mallett S, et al. Evaluation of coagulation abnormalities in acute liver failure. J Hepatol 2012;57:780-6.
  44. Wang DW, Yin YM, Yao YM. Advances in the management of acute liver failure. World J Gastroenterol 2013;19:7069-77.
  45. O′Grady JG, Alexander GJ, Hayllar KM, Williams R. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology 1989;97:439-45.
  46. Neuberger J, Gimson A, Davies M, Akyol M, O′Grady J, Burroughs A, et al. Selection of patients for liver transplantation and allocation of donated livers in the UK. Gut 2008;57:252-7.
  47. Petrowsky H, Busuttil RW. Evolving surgical approaches in liver transplantation. Semin Liver Dis 2009;29:121-33.
  48. Liu CL, Fan ST, Lo CM, Yong BH, Fung AS, Wong J. Right-lobe live donor liver transplantation improves survival of patients with acute liver failure. Br J Surg 2002;89:317-22.
  49. Struecker B, Raschzok N, Sauer IM. Liver support strategies: Cutting-edge technologies. Nat Rev Gastroenterol Hepatol 2014;11:166-76.
  50. Hughes RD, Mitry RR, Dhawan A. Current status of hepatocyte transplantation. Transplantation 2012;93:342-7.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.