Indian National Association for the Study of the Liver Consensus Statement on Acute Liver Failure (Part 1): Epidemiology, Pathogenesis, Presentation and Prognosis

Abstract

Acute liver failure (ALF) is an infrequent, unpredictable, potentially fatal complication of acute liver injury (ALI) consequent to varied etiologies. Etiologies of ALF as reported in the literature have regional differences, which affects the clinical presentation and natural course. In this part of the consensus article designed to reflect the clinical practices in India, disease burden, epidemiology, clinical presentation, monitoring, and prognostication have been discussed. In India, viral hepatitis is the most frequent cause of ALF, with drug-induced hepatitis due to antituberculosis drugs being the second most frequent cause. The clinical presentation of ALF is characterized by jaundice, coagulopathy, and encephalopathy. It is important to differentiate ALF from other causes of liver failure, including acute on chronic liver failure, subacute liver failure, as well as certain tropical infections which can mimic this presentation. The disease often has a fulminant clinical course with high short-term mortality. Death is usually attributable to cerebral complications, infections, and resultant multiorgan failure. Timely liver transplantation (LT) can change the outcome, and hence, it is vital to provide intensive care to patients until LT can be arranged. It is equally important to assess prognosis to select patients who are suitable for LT. Several prognostic scores have been proposed, and their comparisons show that indigenously developed dynamic scores have an edge over scores described from the Western world. Management of ALF will be described in part 2 of this document.

Indian National Association for the Study of Liver Consensus Statement on Acute Liver Failure (Part-2): Management of Acute Liver Failure

“…5 This will be confirmed by finding the hepatitic picture in liver biochemical tests and prolongation of prothrombin time. 1 These patients have significant morbidity and mortality and therefore should be immediately hospitalized and followed up closely. 6 Encephalopathy is an inconsistent and difficult sign to elicit in children, and its grading fraught with subjective bias (See discussion).…”

“…8 Tests to identify acute viral hepatitis should be sought as this is the most common cause of ALF in India. 1 ALF due to hepatitis A virus (HAV) and hepatitis E virus (HEV) infection has a better outcome than ALF from hepatitis B virus (HBV) infection, Wilson disease, drug-induced liver injury (DILI), and cryptogenic. 9 In female patients, one should confirm if the patient is pregnant or not as ALF could be due to pregnancy-specific liver disease which has a modest rise in transaminase and is associated with ascites or hypertension and has a better outcome than ALF from HEV in pregnancy.…”

“…Special care of the airway to avoid ventilator-associated pneumonia in patients with ALF include proper position and physiotherapy, endotracheal lidocaine for suction, and regular sampling of secretions for culture. 1 Percutaneous tracheostomy, if required during weaning, is usually safe and tolerated even in the presence of severe coagulopathy. 81 Consensus statement: Prevention and treatment of respiratory complications…”

“…The term is applied to a clinical presentation of encephalopathy within a few weeks after the onset of liver disease with associated coagulopathy. 1 The overall presentation and differential diagnosis of such cases in India is different than what is described in Western textbooks. Moreover, in India, while tertiary care centers, in general, and liver transplant centers, in particular, may have protocols to optimize the management of patients with ALF, peripheral (primary and secondary care) hospitals may have neither expertise nor resources to care for such patients in an appropriate manner.…”

Pediatric Fibrinogen PART II—Overview of Indications for Fibrinogen Use in Critically Ill Children

“…Most advise against prophylactic replacement of coagulation factors and that replacement be limited to instances of active bleeding or high-risk invasive procedures ( 60 – 63 ). Some guidelines specify that in the context of active bleeding, a fibrinogen level of >100 mg/dL be maintained ( 61 , 64 ).…”