Management of Acute Liver Failure

  • Jessica L. Mellinger
  • Robert J. FontanaEmail author


Acute liver failure (ALF) is defined as the sudden onset of coagulopathy (i.e. elevated INR) and mental status changes in a patient without preexisting liver disease. ALF is an uncommon disorder that can arise from a multitude of etiologies with acetaminophen (APAP) overdose accounting for nearly 50% of adult cases in the US. The clinical course of ALF is highly variable but associated with a high rate of morbidity and mortality. All ALF patients with cerebral edema, renal failure, or an etiology that is associated with a low likelihood of spontaneous recovery should be urgently referred for emergency liver transplant evaluation. Aggressive hemodynamic support, mechanical intubation, preemptive treatment of bacterial and fungal infections, and use of disease specific therapy in selected patients is recommended. Cerebral edema, which is notoriously difficult to diagnose, may arise in 50–70% of ALF patients due to hyperammonemia, high levels of circulating proinflammatory cytokines, and cerebral hyperperfusion. Administration of blood products along with recombinant factor VIIa can allow for the placement of an intracranial pressure (ICP) monitor in ALF patients with stage III or IV encephalopathy. ICP monitors allow intensivists to rationally administer osmotic agents (mannitol and hypertonic saline), vasopressors, and pentobarbital to maintain an adequate cerebral perfusion pressure. Outcomes in ALF patients are largely determined by the etiology of ALF, maximal degree of encephalopathy, and development of multi-organ failure. ICU interventions can help support native liver recovery and also help bridge patients with progressive ALF to emergency liver transplantation.


Acute liver failure Fulminant hepatic failure Encephalopathy Acetaminophen overdose Coagulopathy Cerebral edema Intracranial hypertension Liver transplantation 



The authors would like to thank Dr. William M. Lee of the University of Texas Southwestern, Dallas, for data used in Fig. 70.3. The authors would also like to thank Dr. Krishna Rajajee of the Neuro Critical Care Division at the University of Michigan for his careful review of the manuscript.

Grant Support: Support for Dr. Fontana provided in part by the National Institutes of Diabetes, Digestive, and Kidney Diseases (DK U-01-58369) as a member of the Acute Liver Failure Study Group. Support for Dr. Mellinger provided by the AASLD Advanced Transplant Hepatology Fellowship.


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Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Division of Gastroenterology and Hepatology, Department of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborUSA

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