Cerebral edema and intracranial hypertension in acute liver failure: Distinct aspects of the same problem

Acute liver failure (ALF) remains one of the most dramatic and highly mortal syndromes in modern medicine, with a poor outcome (death or need for emergency liver transplantation) in more than 50% of affected patients. However, prevention of specific etiologies of ALF, general improvements in intensive care medicine, and specific improvements in the management of the systemic complications of ALF, have markedly reduced mortality over the last 40 years. Specific ALF etiologies, including hepatitis A and B, appear to have decreased in developed nations along with improvements in sanitation and widespread vaccination. The management of specific complications—cerebral edema in particular—has lowered the proportion of ALF deaths due to intracranial hypertension, which was once the most dreaded systemic manifestation of ALF. A recent randomized, multicenter trial has documented the efficacy of high-volume plasma exchange in improving transplant-free and overall in-hospital survival. These and other advances have led to a speculation that ALF will be a “curable” clinical condition by the year 2024. Challenges persist, however, as acetaminophen (APAP) overdose continues to account for ~50% of cases of ALF in many developed nations. In the United Kingdom, legislation to limit access to the drug has led to a marked decrease in the incidence of ALF due to acetaminophen overdose: an important lesson for other governments to consider as they work to meet the goal of rendering ALF a “curable” condition. This review contains 6 figures, 10 tables and 53 references Key Words: acetaminophen, acute liver failure, cerebral edema, drug-induced liver injury, extracorporeal liver assist device, fulminant liver failure, hepatic encephalopathy, intracranial hypertension, liver transplantation

Download Full-text

Acute liver failure

Thai Journal of Hepatology ◽

10.30856/th.jhep2018vol1iss1_01 ◽

2018 ◽

Vol 1 (1) ◽

pp. 1-13

Author(s):

Chalermrat Bunchorntavakul

Keyword(s):

Liver Failure ◽

Acute Liver Failure ◽

Intracranial Hypertension ◽

Cerebral Edema ◽

Fungal Infections ◽

Early Recognition ◽

High Morbidity ◽

Term Survival ◽

Extracorporeal Liver Support ◽

Ct Brain

Acute liver failure (ALF) is a life threatening condition defined by the evidence of hepatic injury, jaundice, coagulopathy, and encephalopathy in a patient without preexisting cirrhosis and with an illness duration of <26 weeks. The etiologies of ALF are heterogeneous: viral hepatitis being the most common in the East, whereas drug-induced, particularly acetaminophen, being the most common in the West. Over the past decades, the outcomes of ALF have been improving with early recognition and prompt initiation of etiology-specific therapy (especially N-acetylcysteine), complex intensive care protocols and urgent liver transplantation (LT). The most commonly used prognostic scoring systems include King’s College Criteria (more specific) and MELD (more sensitive). Cerebral edema and intracranial hypertension are reasons for high morbidity and mortality in the early phase; hypertonic saline is suggested for patients with high-risk for developing intracranial hypertension (ICH) and when ICH develops, mannitol is recommended as first-line therapy. Bacterial and fungal infections are very common necessitating strict preventive measures, careful surveillance and prompt aggressive antimicrobial therapy. Acute kidney injury develops in 50-70% of patients; mostly reversible in survivors and temporary dialysis is required in about 30% of cases. Overall 1-year survival after LT has been reported to be lower in patients with ALF as compared to those with cirrhosis; however following the first year this trend has been to be reversed and ALF patients have a better long-term survival. Extracorporeal liver support system, such as albumin dialysis and plasmapheresis, may serve as a bridge to LT and may increase LT-free survival in select cases. Figure 1 CT brain ของผู้ป่วยเพศหญิง อายุ 22 ปี มีภาวะตับวายเฉียบพลันจากยา แรกรับมี encephalopathy grade III CT brain พบ mild cerebral edema with loss of sulciand gyri, blurring of grey - white junctions and mild narrowing of entricles (A) 3 วันหลังเข้ารับการรักษาในโรงพยาบาล ผู้ป่วยมีอาการแย่ลง encephalopathy grade IV, sluggish pupillary response to light botheyes: CT brain พบ progression of cerebral edema, loss of grey-white junctions and brain herniation (B)

Download Full-text

Acute liver failure

Thai Journal of Hepatology ◽

10.30856/th.jhep2018vol1iss1_001 ◽

2018 ◽

Vol 1 (1) ◽

pp. 1-13

Author(s):

Chalermrat l Bunchorntavaku

Keyword(s):

Liver Failure ◽

Acute Liver Failure ◽

Intracranial Hypertension ◽

Cerebral Edema ◽

Fungal Infections ◽

Early Recognition ◽

High Morbidity ◽

Term Survival ◽

Extracorporeal Liver Support ◽

Ct Brain

Acute liver failure (ALF) is a life threatening condition defined by the evidence of hepatic injury, jaundice, coagulopathy, and encephalopathy in a patient without preexisting cirrhosis and with an illness duration of <26 weeks. The etiologies of ALF are heterogeneous: viral hepatitis being the most common in the East, whereas drug-induced, particularly acetaminophen, being the most common in the West. Over the past decades, the outcomes of ALF have been improving with early recognition and prompt initiation of etiology-specific therapy (especially N-acetylcysteine), complex intensive care protocols and urgent liver transplantation (LT). The most commonly used prognostic scoring systems include King’s College Criteria (more specific) and MELD (more sensitive). Cerebral edema and intracranial hypertension are reasons for high morbidity and mortality in the early phase; hypertonic saline is suggested for patients with high-risk for developing intracranial hypertension (ICH) and when ICH develops, mannitol is recommended as first-line therapy. Bacterial and fungal infections are very common necessitating strict preventive measures, careful surveillance and prompt aggressive antimicrobial therapy. Acute kidney injury develops in 50-70% of patients; mostly reversible in survivors and temporary dialysis is required in about 30% of cases. Overall 1-year survival after LT has been reported to be lower in patients with ALF as compared to those with cirrhosis; however following the first year this trend has been to be reversed and ALF patients have a better long-term survival. Extracorporeal liver support system, such as albumin dialysis and plasmapheresis, may serve as a bridge to LT and may increase LT-free survival in select cases. Figure 1 CT brain ของผู้ป่วยเพศหญิง อายุ 22 ปี มีภาวะ ตับวายเฉียบพลันจากยา แรกรับมี encephalopathy grade III CT brain พบ mild cerebral edema with loss of sulci and gyri, blurring of grey - white junctions and mild narrowing of ventricles (A) 3 วันหลังเข้ารับการรักษา ในโรงพยาบาล ผู้ป่วยมีอาการแย่ลง encephalopathy grade IV, sluggish pupillary response to light both eyes: CT brain พบ progression of cerebral edema, loss of grey-white junctions and brain herniation (B)

Download Full-text

Acute Liver Failure

10.2310/gastro.14001 ◽

2018 ◽

Author(s):

Constantine J Karvellas ◽

R. Todd Stravitz

Keyword(s):

Liver Transplantation ◽

Liver Failure ◽

Acute Liver Failure ◽

Intracranial Hypertension ◽

Cerebral Edema ◽

High Volume ◽

Important Lesson ◽

Drug Induced ◽

Systemic Complications ◽

Developed Nations

Acute liver failure (ALF) remains one of the most dramatic and highly mortal syndromes in modern medicine, with a poor outcome (death or need for emergency liver transplantation) in more than 50% of affected patients. However, prevention of specific etiologies of ALF, general improvements in intensive care medicine, and specific improvements in the management of the systemic complications of ALF, have markedly reduced mortality over the last 40 years. Specific ALF etiologies, including hepatitis A and B, appear to have decreased in developed nations along with improvements in sanitation and widespread vaccination. The management of specific complications—cerebral edema in particular—has lowered the proportion of ALF deaths due to intracranial hypertension, which was once the most dreaded systemic manifestation of ALF. A recent randomized, multicenter trial has documented the efficacy of high-volume plasma exchange in improving transplant-free and overall in-hospital survival. These and other advances have led to a speculation that ALF will be a “curable” clinical condition by the year 2024. Challenges persist, however, as acetaminophen (APAP) overdose continues to account for ~50% of cases of ALF in many developed nations. In the United Kingdom, legislation to limit access to the drug has led to a marked decrease in the incidence of ALF due to acetaminophen overdose: an important lesson for other governments to consider as they work to meet the goal of rendering ALF a “curable” condition. This review contains 6 figures, 10 tables and 53 references Key Words: acetaminophen, acute liver failure, cerebral edema, drug-induced liver injury, extracorporeal liver assist device, fulminant liver failure, hepatic encephalopathy, intracranial hypertension, liver transplantation

Download Full-text

Intracranial hypertension in acute liver failure

Nephrology Dialysis Transplantation ◽

10.1093/ndt/17.1.23 ◽

2002 ◽

Vol 17 (1) ◽

pp. 23-27 ◽

Cited By ~ 12

Author(s):

D. Richardson

Keyword(s):

Liver Failure ◽

Acute Liver Failure ◽

Intracranial Hypertension

Download Full-text

Acute Hepatic Failure

10.2310/surg.2412 ◽

2019 ◽

Author(s):

Derek J Erstad ◽

Motaz Qadan

Keyword(s):

Intensive Care ◽

Respiratory Distress Syndrome ◽

Liver Failure ◽

Respiratory Distress ◽

Acute Liver Failure ◽

Fulminant Hepatic Failure ◽

Cerebral Edema ◽

Hepatic Failure ◽

Distress Syndrome ◽

Diagnosis And Management

Acute liver failure (ALF) is a rare but highly morbid condition that is optimally managed by a multidisciplinary team of surgeons, hepatologists, and intensivists at a tertiary care center that specializes in liver disorders. ALF is caused by four primary mechanisms, including viral infections (most commonly Hepatitis A and B); toxicity from acetaminophen overdose or other substances; postoperative hepatic failure ; and miscellaneous causes such as autoimmune hepatitis, genetic disorders, or idiopathic etiologies. Unlike chronic liver failure in which the body develops compensatory, protective mechanisms, ALF may be associated with severe multisystem organ involvement, including respiratory distress syndrome, renal failure, and cerebral edema. Fulminant hepatic failure represents a rapidly progressive form of ALF that portends worse prognosis. Prompt diagnosis and management of multisystem organ dysfunction in an intensive care setting is paramount to survival. However, a subset of patients will fail to improve with medical management alone. Early identification of these individuals for emergent transplant listing has been shown to improve outcomes. Multiple predictive models for ALF survival have been developed, which are based on weighted evaluation of clinical and laboratory parameters. These models may be used to facilitate treatment, predict prognosis, and guide transplant listing. In this chapter, we provide an in-depth review these concepts, focusing on the classification, epidemiology, diagnosis, and management of ALF. This review contains 5 tables and 69 references. Key Words: acute liver failure, acute respiratory distress syndrome, coagulopathy, cerebral edema, fulminant hepatic failure, hepatic necrosis, liver transplantation, metabolic disarray, multidisciplinary intensive care, prognostication

Download Full-text