Hemodynamic Changes and Modulation in Inpatients with Acute and Chronic Liver Failure

  • Ahmed M. MukhtarEmail author


Patients on the waiting list for a liver transplant are frequently admitted to an intensive care unit (ICU) due to decompensation of the liver function [1]. Hemodynamic management of this patient population can be very challenging. There are two distinct types of acute liver dysfunction that might require ICU admission: acute liver failure (ALF) and acute on chronic liver failure (ACLF). Although both types of liver dysfunction are presented with multi-system involvement, the underlying pathophysiological changes responsible for hemodynamic instability differ significantly between the conditions, such that each requires specific management.


  1. 1.
    Findlay JY, Fix OK, Paugam-burtz C, et al. Critical care of the end-stage liver disease patient awaiting liver transplantation. Liver Transpl. 2011;17:496–510.PubMedCrossRefGoogle Scholar
  2. 2.
    Wendon J, Cordoba J, Dhawan A, et al. Clinical practice guidelines EASL clinical practical guidelines on the management of acute (fulminant) liver failure q clinical practice guidelines [Internet]. J Hepatol. 2017;66:1047–81. Available from: Scholar
  3. 3.
    Ford RM, Sakaria SS, Subramanian RM. Critical care management of patients before liver transplantation [Internet]. Transplant Rev. 2010;24:190–206. Available from: Scholar
  4. 4.
    Wang D-W. Advances in the management of acute liver failure [Internet]. World J Gastroenterol. 2013;19:7069. Available from: Scholar
  5. 5.
    Siniscalchi A, Dante A, Spedicato S, et al. Hyperdynamic circulation in acute liver failure: reperfusion syndrome and outcome following liver transplantation. Transplant Proc. 2010;42:1197–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Ellis A, Wendon J. Circulatory, respiratory, cerebral, and renal derangements in acute liver failure: pathophysiology and management. Semin Liver Dis. 1996;16:379–88.PubMedCrossRefGoogle Scholar
  7. 7.
    Vaquero J, Polson J, Chung C, et al. Infection and the progression of hepatic encephalopathy in acute liver failure. Gastroenterology. 2003;125:755–64.PubMedCrossRefGoogle Scholar
  8. 8.
    Harry R, Auzinger G, Wendon J. The clinical importance of adrenal insufficiency in acute hepatic dysfunction. Hepatology. 2002;36:395–402.PubMedCrossRefGoogle Scholar
  9. 9.
    Kandiah PA, Olson JC, Subramanian RM. Emerging strategies for the treatment of patients with acute hepatic failure [Internet]. Curr Opin Crit Care. 2016;22:1. Available from: Scholar
  10. 10.
    Asfar P, Meziani F, Hamel J-F, et al. High versus low blood-pressure target in patients with septic shock. N Engl J Med. 2014;370:1583–93.PubMedCrossRefGoogle Scholar
  11. 11.
    Acheampong A, Vincent J. A positive fluid balance is an independent prognostic factor in patients with sepsis [Internet]. Crit Care. 2015;19:1–7. Available from: Scholar
  12. 12.
    Audimoolam VK, Mcphail MJW, Willars C, et al. Predicting fluid responsiveness in acute liver. Anesth Analg. 2017;124:480–6.PubMedCrossRefGoogle Scholar
  13. 13.
    Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense*. Crit Care Med. 2013;41:1774–81.PubMedCrossRefGoogle Scholar
  14. 14.
    Scheuermann K, Thiel C, Thiel K, et al. Correlation of the intracranial pressure to the central venous pressure in the late phase of acute liver failure in a porcine model. Acta Neurochir Suppl. 2012;114:387–91.PubMedCrossRefGoogle Scholar
  15. 15.
    el-Masry A, Mukhtar AM, el-Sherbeny AM, et al. Comparison of central venous oxygen saturation and mixed venous oxygen saturation during liver transplantation. Anaesthesia. 2009;64:378–82.PubMedCrossRefGoogle Scholar
  16. 16.
    Lee YK, Hwang SY, Shin TG, et al. Prognostic value of lactate and central venous oxygen saturation after early resuscitation in sepsis patients. PLoS One. 2016;11:e0153305.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43:304–77.PubMedCrossRefGoogle Scholar
  18. 18.
    Hasanin A. Fluid responsiveness in acute circulatory failure. J Intensive Care. 2015;19(3):50.CrossRefGoogle Scholar
  19. 19.
    Yang X, Du B. Does pulse pressure variation predict fluid responsiveness in critically ill patients? A systematic review and meta-analysis. Crit Care. 2014;18:650.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Monnet X, Rienzo M, Osman D, et al. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med. 2006;34:1402–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Muller L, Toumi M, Bousquet P-J, et al. An increase in aortic blood flow after an infusion of 100 ml colloid over 1 minute can predict fluid responsiveness. Anesthesiology. 2011;115:541–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Krajewski ML, Raghunathan K, Paluszkiewicz SM, et al. Meta-analysis of high- versus low- chloride content in perioperative and critical care fluid resuscitation. Br J Surg. 2015;102:24–36.PubMedCrossRefGoogle Scholar
  23. 23.
    Barrett LK, Singer M, Clapp LH. Vasopressin: mechanisms of action on the vasculature in health and in septic shock. Crit Care Med. 2007;35:33–40.PubMedCrossRefGoogle Scholar
  24. 24.
    Nilsson G, Lindblom P, Ohlin M, et al. Pharmacokinetics of terlipressin after single i.v. doses to healthy volunteers. Drugs Exp Clin Res. 1990;16:307–14.PubMedGoogle Scholar
  25. 25.
    Shawcross DL, Davies NA, Mookerjee RP, et al. Worsening of cerebral hyperemia by the administration of terlipressin in acute liver failure with severe encephalopathy. Hepatology. 2004;39:471–5.PubMedCrossRefGoogle Scholar
  26. 26.
    Eefsen M, Dethloff T, Frederiksen H-J, et al. Comparison of terlipressin and noradrenalin on cerebral perfusion, intracranial pressure and cerebral extracellular concentrations of lactate and pyruvate in patients with acute liver failure in need of inotropic support [Internet]. J Hepatol. 2007;47:381–6. Available from: Scholar
  27. 27.
    Harry R, Auzinger G, Wendon J. The effects of supraphysiological doses of corticosteroids in hypotensive liver failure. Liver Int. 2003;23:71–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Clemmesen JO, Kondrup J, Nielsen LB, et al. Effects of high-volume plasmapheresis on ammonia, urea, and amino acids in patients with acute liver failure. Am J Gastroenterol. 2001;96:1217–23.PubMedCrossRefGoogle Scholar
  29. 29.
    Clemmesen JO, Gerbes AL, Gülberg V, et al. Hepatic blood flow and splanchnic oxygen consumption in patients with liver failure. Effect of high-volume plasmapheresis. Hepatology. 1999;29:347–55.PubMedCrossRefGoogle Scholar
  30. 30.
    Larsen FS, Schmidt LE, Bernsmeier C, et al. High-volume plasma exchange in patients with acute liver failure: an open randomised controlled trial. J Hepatol. 2016;64:69–78.PubMedCrossRefGoogle Scholar
  31. 31.
    Guirl MJ, Weinstein JS, Goldstein RM, et al. Two-stage total hepatectomy and liver transplantation for acute deterioration of chronic liver disease: a new bridge to transplantation. [Internet]. Liver Transplant. 2004;10:564–70. Available from: Scholar
  32. 32.
    Bellot P, García-Pagán JC, Francés R, et al. Bacterial DNA translocation is associated with systemic circulatory abnormalities and intrahepatic endothelial dysfunction in patients with cirrhosis. [Internet]. Hepatology. 2010;52:2044–52. [cited 2014 Nov 10] Available from: Scholar
  33. 33.
    Henriksen JH. Volume adaptation in chronic liver disease: on the static and dynamic location of water, salt, protein and red cells in cirrhosis. [Internet]. Scand J Clin Lab Invest. 2004;64:523–33. [cited 2014 Nov 10] Available from: Scholar
  34. 34.
    The passive leg-raising maneuver cannot accurately predict fluid responsiveness in patients with intra-abdominal hypertension [Internet]. Available from: pubmed/20639753.
  35. 35.
    Hadengue A, Moreau R, Gaudin C, et al. Total effective vascular compliance in patients with cirrhosis: a study of the response to acute blood volume expansion. Hepatology. 1992;15:809–15.PubMedCrossRefGoogle Scholar
  36. 36.
    Jacques D, Bendjelid K, Duperret S, et al. Pulse pressure variation and stroke volume variation during increased intra-abdominal pressure: an experimental study. Crit Care. 2011;15:R33.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Sterling SA, Puskarich MA, Jones AE. The effect of liver disease on lactate normalization in severe sepsis and septic shock: a cohort study. Clin Exp Emerg Med. 2015;2:197–202.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Choudhury A, Kedarisetty CK, Vashishtha C, et al. A randomized trial comparing terlipressin and noradrenaline in patients with cirrhosis and septic shock. Liver Int. 2017;37:552–61.PubMedCrossRefGoogle Scholar
  39. 39.
    Hollenberg SM. The circulatory system in liver disease [Internet]. Crit Care Clin. 2017;32:331–42. Available from: Scholar
  40. 40.
    Wu C, Cheng Y, Liu Y, et al. Predicting stroke volume and arterial pressure fluid responsiveness in liver cirrhosis patients using dynamic preload variables. A prospective study of diagnostic accuracy. Eur J Anaesthesiol. 2016;33:645–52.PubMedCrossRefGoogle Scholar
  41. 41.
    Monnet X, Marik PE, Teboul J-L. Prediction of fluid responsiveness: an update [Internet]. Ann Intensive Care. 2016;6:111. Available from: Scholar
  42. 42.
    Kitamura H, Kobayashi C. Impairment of change in diameter of the hepatic portion of the inferior vena cava – a sonographic sign of liver fibrosis or cirrhosis. J Ultrasound Med. 2005;24:355–9.PubMedCrossRefGoogle Scholar
  43. 43.
    Fernández J, Monteagudo J, Bargallo X, Jiménez W, Bosch J, Arroyo V, Navasa M. A randomized unblinded pilot study comparing albumin versus hydroxyethyl starch in spontaneous bacterial peritonitis. Hepatology. 2005;42:627–34.CrossRefGoogle Scholar
  44. 44.
    Albillos A, Rossi I, Cacho G, et al. Enhanced endothelium-dependent vasodilation in patients with cirrhosis. Am J Phys. 1995;268:G459–64.Google Scholar
  45. 45.
    Mukhtar A, Dabbous H. Modulation of splanchnic circulation: role in perioperative management of liver transplant patients. World J Gastroenterol. 2016;22:1582–92.PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    Wagener G, Gubitosa G, Renz J, et al. Vasopressin decreases portal vein pressure and flow in the native liver during liver transplantation. [Internet]. Liver Transpl. 2008;14:1664–70. [cited 2014 Nov 10] Available from: Scholar
  47. 47.
    Moreau R, Cailmail S, Lebrec D. Effects of vasopressin on haemodynamics in portal hypertensive rats receiving clonidine. Liver. 1994;14:45–9.PubMedCrossRefGoogle Scholar
  48. 48.
    Freeman JG, Cobden I, Lishman AH, et al. Controlled trial of terlipressin (‘Glypressin’) versus vasopressin in the early treatment of oesophageal varices. Lancet. 1982;2:66–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Kiszka-Kanowitz M, Henriksen JH, Hansen EF, et al. Effect of terlipressin on blood volume distribution in patients with cirrhosis [Internet]. Scand J Gastroenterol. 2004;39:486–92. [cited 2014 Nov 10] Available from: Scholar
  50. 50.
    Mukhtar A, Salah M, Aboulfetouh F, et al. The use of terlipressin during living donor liver transplantation: effects on systemic and splanchnic hemodynamics and renal function. [Internet]. Crit Care Med. 2011;39:1329–34. [cited 2014 Aug 22] Available from: http://www.
  51. 51.
    Marik PE, Gayowski T, Starzl TE, et al. The hepatoadrenal syndrome: a common yet unrecognized clinical condition. Crit Care Med. 2005;33:1254–9.PubMedPubMedCentralCrossRefGoogle Scholar
  52. 52.
    Fernández J, Escorsell A, Zabalza M, et al. Adrenal insufficiency in patients with cirrhosis and septic shock: effect of treatment with hydrocortisone on survival. Hepatology. 2006;44:1288–95.PubMedCrossRefGoogle Scholar
  53. 53.
    Arabi YM, Aljumah A, Dabbagh O, et al. Low-dose hydrocortisone in patients with cirrhosis and septic shock: a randomized controlled trial. CMAJ. 2010;182:1971–7.PubMedPubMedCentralCrossRefGoogle Scholar
  54. 54.
    Evans T, Carpenter A, Kinderman H, et al. Evidence of increased nitric oxide production in patients with the sepsis syndrome. Circ Shock. 1993;41:77–81.PubMedGoogle Scholar
  55. 55.
    Hosseinian L, Weiner M, Levin MA, et al. Methylene blue: magic bullet for vasoplegia? Anesth Analg. 2016;122:194–201.PubMedCrossRefGoogle Scholar
  56. 56.
    Cheng SS, Berman GW, Merritt GR, et al. The response to methylene blue in patients with severe hypotension during liver transplantation. J Clin Anesth. 2012;24:324–8.PubMedCrossRefGoogle Scholar
  57. 57.
    Fischer GW, Bengtsson Y, Scarola S, et al. Methylene blue for vasopressor-resistant vasoplegia syndrome during liver transplantation [Internet]. J Cardiothorac Vasc Anesth. 2010;24:463–6. Available from: Scholar
  58. 58.
    Ramamoorthy S, Patel S, Bradburn E, et al. Use of methylene blue for treatment of severe sepsis in an immunosuppressed patient after liver transplantation [Internet]. Case Rep Transplant. 2013;2013:1–4. Available from: Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Anesthesia and Critical CareCairo UniversityCairoEgypt

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