Recommendations developed for management of acute liver failure

In a clinical guideline issued by the American College of Gastroenterology and published in the July issue of the American Journal of Gastroenterology, recommendations are presented for the identification, treatment, and management of acute liver failure (ALF).

Alexandra Shingina, M.D., from the Vanderbilt University Medical Center in Nashville, Tennessee, and colleagues reviewed the scientific evidence to develop recommendations for identification, treatment, and management of ALF.

The authors developed 10 recommendations (four strong; six conditional) and summarized expert opinions using key concepts when no robust evidence was available. The strong recommendations included use of norepinephrine as the first-line vasopressor for hypotension refractory to fluid resuscitation; early administration of N-acetylcysteine (NAC) in patients with suspected N-acetyl-p-aminophenol (APAP) toxicity; initiation of intravenous NAC in patients with non-APAP ALF; and starting antiviral therapy in patients with ALF due to reactivation of hepatitis B virus.

Conditional recommendations included not using routine correction of coagulopathy in the absence of active bleeding or an impending high-risk procedure and not using prophylactic antimicrobial agents routinely, given no improvement in either rate of blood stream infection or 21-day mortality. In terms of general management, comprehensive testing is essential to elucidate a diagnosis and exclude underlying chronic liver disease.

"ALF is a medical emergency and is potentially reversible if recognized and treated early," the authors write. "ALF must be differentiated from acute-on-chronic liver failure and decompensated cirrhosis because management is vastly different."