Acute Liver Failure in the ICU

  • E. Sizer
  • J. Wendon
  • W. Bernal
Conference paper


Acute liver failure is a rare clinical syndrome resulting from severe hepatocyte injury, usually in the absence of pre-existing chronic liver disease. It is characterized by the onset of encephalopathy following the liver injury; jaundice is present in most patients but, in cases of hyperacute liver failure, encephalopathy may precede clinical jaundice. The prognosis in acute liver failure is variable, with mortality ranging from 10–90% without transplantation. The important factors determining outcome are principally: underlying etiology, age of the patient and time course over which the syndrome develops [1].


Intracranial Hypertension Hypertonic Saline Acute Liver Failure Fulminant Hepatic Failure Optic Nerve Sheath Diameter 
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  1. 1.
    O’Grady J (2000) Acute liver failure. In: O’Grady J, Lake J, Howdle P (eds) Comprehensive Clinical Hepatology, lst edn. Mosby, London, pp 30.1–30. 2Google Scholar
  2. 2.
    O’Grady JG, Schalm SW, Williams R (1993) Acute liver failure: redefining the syndromes. Lancet 342: 273–275PubMedCrossRefGoogle Scholar
  3. 3.
    O’Grady JG, Alexander GJ, Hayllar KM, Williams R (1989) Early indicators of prognosis in fulminant hepatic failure. Gastroenterology 97: 439–445PubMedGoogle Scholar
  4. 4.
    Shakil A, Kramer D, Mazariegos G, Fung J, Rakella J (2000) Acute liver failure: clinical features, outcome analysis, and applicability of prognostic criteria. Liver Transplant 6: 163–169Google Scholar
  5. 5.
    Makin A, Wendon J, Williams R (1995) A 7 year experience of severe acetominophen-induced hepatotoxicity (1987–1993). Gastroenterology 109: 1907–1916PubMedCrossRefGoogle Scholar
  6. 6.
    Mitchell I, Bihari D, Chang R, Wendon J, Williams R (1997) Earlier identification of patients at risk from acetominophen induced acute liver failure. Crit Care Med 26: 279–284CrossRefGoogle Scholar
  7. 7.
    Bernal W, Wendon J, Rela M, Heaton N, Williams R (1998) Use and outcome of liver transplantation in acetominophen induced acute liver failure. Hepatology 27: 1050–1055PubMedCrossRefGoogle Scholar
  8. 8.
    Bernal W, Donaldson N, Wyncoll D, Wendon J (2002) Blood lactate as an early predictor of outcome in paracetamol-induced acute liver failure: a cohort study. Lancet 358: 558–563CrossRefGoogle Scholar
  9. 9.
    Lerut J, Ciccarelli O, Roggen F, et al (2000) Progress in adult liver transplantation for acute liver failure. Transplantation Proc 32: 2704–2706CrossRefGoogle Scholar
  10. 10.
    Chenard-Neu MP, Boudjema K, Bernau J, et al (1996) Auxiliary liver transplantation: regeneration of the native liver and outcome in 30 patients with fulminant hepatic failure. A multicentre European study. Hepatology 23: 1119–1127Google Scholar
  11. 11.
    Blei A, Larsen F (1999) Pathophysiology of cerebral edema in fulminant hepatic failure. J Hepatol 31: 771–776PubMedCrossRefGoogle Scholar
  12. 12.
    Traber P, DalCanto M, Ganger D, Blei AT (1989) Effect of body temperature on brain edema and encephalopathy in the rat after hepatic devascularisation. Gastroenterology 96: 885–891PubMedGoogle Scholar
  13. 13.
    Marion DW, Penrod LE, Kelsey SF, et al (1997) Treatment of traumatic brain injury with moderate hypothermia. N Engl J Med. 336: 540–546PubMedCrossRefGoogle Scholar
  14. 14.
    Busto R, Dietrich WD, Globus MYT, Valdes I, Scheinberg P, Ginsberg MD (1987) Small differences in intra-ischaemic brain temperature critically determine the extent of ischaemic neuronal injury. J Cereb Blood Flow Metab 7: 729–738PubMedCrossRefGoogle Scholar
  15. 15.
    Rose C, Michalak A, Pannuzio M, Chatauret N, Rambaldi A, Butterworth R (2000) Mild hypothermia delays the onset of coma and prevents brain edema and extracellular brain glutamate accumulation in rats with acute liver failure. Hepatology 31: 872–877PubMedCrossRefGoogle Scholar
  16. 16.
    Vogels BAPM, Mass MAW, Daalhuisen J, Quack G, Chamuleau RAFM (1997) Memantine, a non-competitive NMDA-receptor antagonist improves hyperammonia-induced encephalopathy and acute hepatic encephalopathy in rats. Hepatology 25: 820–827PubMedCrossRefGoogle Scholar
  17. 17.
    Keays RT, Alexander GJM, Williams R (1993) The safety and value of extradural intracranial pressure monitors in fulminant hepatic failure. J Hepatol 18: 205–209PubMedCrossRefGoogle Scholar
  18. 18.
    Blei AT, Olafsson S, Webster S, Levy R (1993) Complications of intracranial pressure monitoring in fulminant hepatic failure. Lancet 34: 690–691Google Scholar
  19. 19.
    Kudo M (2001) Cerebral vascular resistance in hepatic insufficiency. J Gastroenterol Hepatol 16: 845–847PubMedCrossRefGoogle Scholar
  20. 20.
    Srauss GI, Moller K, Holm S, Sperling B, Knudsen GM, Larsen FS (2001) Transcranial Doppler sonography and internal jugular bulb saturation during hyperventilation in patients with fulminant hepatic failure. Liver Transpl 7: 352–358CrossRefGoogle Scholar
  21. 21.
    Helme K, Burdelski M, Hansen HC (2000) Detection and monitoring of intracranial pressure dysregulation in liver failure by ultrasound. Transplantation 70: 392–395CrossRefGoogle Scholar
  22. 22.
    Donovan JP, Shaw BW Jr, Langnas AN, Sorrell MF (1992) Brain water and acute liver failure: the emerging role of intracranial pressure monitoring. Hepatology 16: 267–268PubMedCrossRefGoogle Scholar
  23. 23.
    Lucey MR, Brown KA, Everson GT, et al (1997) Minimal criteria for placement of adults on the liver transplant waiting list: a report of a national conference organized by the American Society of Transplant Physicians and the American Association for the Study of Liver Diseases. Liver Transpl Surg 3: 628–637PubMedCrossRefGoogle Scholar
  24. 24.
    Davies MH, Mutimer D, Lowes J, Elias E, Neuberger J (1994) Recovery despite impaired cerebral perfusion in fulminant hepatic failure. Lancet 343: 1329–1330PubMedCrossRefGoogle Scholar
  25. 25.
    Davenport A, Will EJ, Davison AM (1990) Effect of posture on intracranial pressure and cerebral perfusion pressure in patients with fulminant hepatic failure and renal failure after acetominophen self-poisoning. Crit Care Med 18: 286–289PubMedCrossRefGoogle Scholar
  26. 26.
    Hanid MA, Davies M, Mellon PJ, et al (1980) Clinical monitoring of intracranial pressure in fulminant hepatic failure. Gut 21: 866–869PubMedCrossRefGoogle Scholar
  27. 27.
    Inoue S, Ninaga H, Kawaguchi M, Furuya H (1998) A case of shock subsequent to treatment of intracranial hypertension by mannitol injection combined with hyperventilation. J Neurosurg Anesthesiol 10: 113–115PubMedCrossRefGoogle Scholar
  28. 28.
    Nau R (2000) Osmotherapy for elevated intracranial pressure: a critical reappraisal. Clin Pharmacokinet 38: 23–40PubMedCrossRefGoogle Scholar
  29. 29.
    Kelly DF, Goodale DB, Williams J, et al (1999) Propofol in the treatment of moderate and severe head injury: a randomised, prospective double-blinded pilot trial. J Neurosurg 90: 1042–1052PubMedCrossRefGoogle Scholar
  30. 30.
    Sakai K, Cho S, Fukusaki M, Shibata M, Sumikawa K (2000) The effects of Propofol with and without Ketamine on human cerebral blood flow velocity and CO2 response. Anesth Analg 90: 377–382PubMedGoogle Scholar
  31. 31.
    Horn P, Munch E, Vajkoczy P, et al (1999) Hypertonic saline solution for control of elevated pressure in patients with exhausted response to mannitol and barbiturates. Neurol Res 21: 758–764PubMedGoogle Scholar
  32. 32.
    Strauss G, Hansen BA, Knudsen GM, Larsen FS (1998) Hyperventilation restores cerebral blood flow autoregulation in patients with acute liver failure. J Hepatol 28: 199–203PubMedCrossRefGoogle Scholar
  33. 33.
    Wendon JA, Harrison PM, Keays R, Williams R (1994) Cerebral blood flow and metabolism in fulminant liver failure. Hepatology 19: 1407–1013PubMedCrossRefGoogle Scholar
  34. 34.
    Larsen FS, Knudsen GM, Hansen BA (1997) Pathophysiological changes in cerebral circulation, oxidative metabolism and blood-brain barrier in patients with cute liver failure. J Hepatol 27: 231–238PubMedCrossRefGoogle Scholar
  35. 35.
    Jalan R, Damink S, Deutz N, Lee A, Hayes P (1999) Moderate hypothermia for uncontrolled intracranial hypertension in acute liver failure. Lancet 354: 1164–1168PubMedCrossRefGoogle Scholar
  36. 36.
    Harrigan MR, Tuteja S, Neudeck BL (1997) Indomethacin in the management of elevated intracranial pressure: a review. J Neurotrauma 14: 637–650PubMedCrossRefGoogle Scholar
  37. 37.
    Markus HS, Vallance P, Brown MM (1994) Differential effect of three cyclooxygenase inhibitors on human cerebral blood flow velocity and carbon dioxide reactivity. Stroke 25: 1760–1764PubMedCrossRefGoogle Scholar
  38. 38.
    Jensen K, Ohrstrm J, Cold GE, Astrup J (1991) The effects of indomethacin on intracranial pressure, cerebral blood flow and cerebral metabolism in patients with severe head injury and intracranial hypertension. Acta Neurochir 108: 116–121PubMedCrossRefGoogle Scholar
  39. 39.
    Clemmesen JO, Hansen BA, Larsen FS (1997) Indomethacin normalizes intracranial pressure in acute liver failure: a twenty-three-year-old woman treated with indomethacin. Hepatology 26: 1423–1425PubMedCrossRefGoogle Scholar
  40. 40.
    Rozga J, Podesta L, LePage E, et al (1993) Control of cerebral edema by total hepatectomy and extracorporeal liver support in fulminant hepatic failure. Lancet 342: 898–899PubMedCrossRefGoogle Scholar
  41. 41.
    Jalan R, Pollok A, Shah S, Madhaven K, Simpson K (2002) Liver derived pro-inflammatory cytokines may be important in producing intracranial hypertension in acute liver failure. J Hepatol 73: 536–538CrossRefGoogle Scholar
  42. 42.
    Rolando N, Philpott-Howard J, Williams R (1996) Bacterial and fungal infection in acute liver failure. Semin Liver Dis 16: 389–402PubMedCrossRefGoogle Scholar
  43. 43.
    Rolando N, Wade J, Davalos M, Wendon J, Philpott-Howard J, Williams R (2000) The systemic inflammatory response syndrome in acute liver failure. Hepatology 32: 734–739PubMedCrossRefGoogle Scholar
  44. 44.
    Takada Y, Ishiguro S, Fukunaga K, et al (2001) Increased intracranial pressure in a porcine model of fulminant hepatic failure using amatoxin and endotoxin. J Hepatol 6:825–831 45 Moore K (1999) Renal failure in acute liver failure. Eur J Gastroenterol Hepatol 11: 967–975Google Scholar
  45. 46.
    Moore K, Wendon J, Frazer M, Karani J, Williams R, Badr K (1992) Plasma endothelin immunoreactivity in liver disease and the hepatorenal syndrome. N Engl J Med 327: 17741778Google Scholar
  46. 47.
    Davenport A, Will EJ, Davison AM (1991) Continuous vs intermittent forms of haemofiltration and/or dialysis in the management of acute renal failure in patients with defective cerebral autoregulation at risk of cerebral oedema. Contrib Nephrol 93: 225–233PubMedGoogle Scholar
  47. 48.
    Cole 1, Bellomo R, Journois D, Davenport P, Baldwin I, Tipping P (2001) High-volume haemofiltration in human septic shock. Intensive Care Med 27: 978–986PubMedCrossRefGoogle Scholar
  48. 49.
    Clemmesen JE, Kondrop J, Nielsen LB, Larsen FS, Ott P (2001) Effects of high-volume plasmapharesis on ammonia, urea, and amino acids in patients with acute liver failure. Am J Gastroenterol 96: 1217–1223PubMedCrossRefGoogle Scholar
  49. 50.
    Ho DWY, Fan ST, To J, et al (2002) Selective plasma filtration for treatment of fulminant hepatic failure induced by D-galactosamine in a pig model. Gut 50: 869–876PubMedCrossRefGoogle Scholar
  50. 51.
    Murphy ND, Kodakat SK, Wendon J, et al (2001) Liver and Intestinal lactate metabolism in patients with acute hepatic failure undergoing liver transplantation. Crit Care Med 29: 2111–2118PubMedCrossRefGoogle Scholar
  51. 52.
    Leifeld L, Fielenbach M, Dumoulin FL, Speidel N, Saauerbruch T, Spengler U (2002) Inducible nitric oxide synthase (iNOS) and endothelial nitric oxide synthase (eNOS) expression in fulminant hepatic failure J Hepatol 37: 613–619Google Scholar
  52. 53.
    Harry R, Auzinger G, Wendon J (2002) The clinical importance of adrenal insufficiency in acute hepatic dysfunction. Hepatology 36: 395–402PubMedCrossRefGoogle Scholar
  53. 54.
    Van den Berghe G, Wouters P, Weekers F, et al (2001) Intensive insulin therapy in the critically ill patient. N Engl J Med 345: 1359–1367PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2003

Authors and Affiliations

  • E. Sizer
  • J. Wendon
  • W. Bernal

There are no affiliations available

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