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Acute liver failure (ALF) is a rare and severe hepatocellular injury syndrome.
The patient has no previous liver disease and is characterized by sudden and severe hepatocyte dysfunction (jaundice, coagulopathy, and encephalopathy)
.
The disease can rapidly progress to coma, leading to death due to cerebral edema and multiple organ failure
.
It is called "syndrome" because ALF has many causes, and the course and prognosis of different causes are different
.
Therefore, determining the cause of acute liver failure is essential for guiding treatment, predicting prognosis, and evaluating whether liver transplantation is needed
.
The five most common causes in developed countries are: paracetamol toxicity, ischemia, drug-induced liver injury, hepatitis B virus, and autoimmune hepatitis.
These causes account for nearly 80% of the total number of cases
.
In contrast, viral hepatitis A, B and E (HAV, HBV, HEV) are the main causes of ALF in developing countries
.
Table 1 Population distribution of different causes of ALF, laboratory test results at admission, and prognosis comparison (data from the American Adult Acute Liver Failure Research Group) Note: Acute liver injury caused by acetaminophen is common in developed countries, and liver is rare in Asian countries Insufficiency of oxygenated blood volume in the ischemic liver has many causes, and leads to hyperacute but self-limiting liver injury, which is characterized by a high concentration of transaminase and a low concentration of bilirubin
.
Except for a few reasons (such as heatstroke and cocaine toxicity), transaminase concentrations greater than 3000 IU/L and bilirubin concentrations less than 5.
0 mg/dL are common in liver ischemia and acetaminophen poisoning (Table 1)
.
An echocardiogram showing a drop in left ventricular ejection fraction indicates ischemia caused by severe heart failure
.
Other causes of poor perfusion include hypotension (shock) caused by decreased blood volume, septic shock, tissue hypoxia (such as respiratory depression caused by opioids), lung failure, and cocaine use
.
In these cases, the incidence of acute kidney injury and acute liver injury are almost the same
.
Although the intravascular volume can be restored and cardiac hemodynamics can be quickly improved, the short-term prognosis of ALF caused by ischemia is good; but if the underlying cause of hemodynamic damage is irreversible, the long-term prognosis is still uncertain
.
Liver ischemic injury rarely requires liver transplantation, unless the cause is direct damage to liver blood circulation (such as hepatic artery embolism)
.
Drug-induced liver injury Specific drug-induced liver injury is the second most common cause of ALF after acetaminophen, and its prognosis is poor
.
Only 10% of patients with drug-induced liver injury have acute liver failure, and there is a possibility of liver transplantation or death
.
This idiosyncratic hepatotoxicity is believed to be based on an immune response, and some individuals are genetically susceptible
.
Antibiotics account for almost 50% of all drug-induced liver injury cases, partly because they are more commonly used and usually at higher doses (ie at least 500-1000 mg per day), which increases the risk of liver injury
.
Compared with viral acute liver failure, there is no specific diagnostic test for drug-induced liver injury
.
Determining a particular drug requires a careful medical history and exclusion of other causes
.
Compared with liver ischemia and acetaminophen, drug-induced acute liver failure is accompanied by lower transaminase concentration and high bilirubin concentration (Table 1)
.
Autoimmune hepatitis Acute liver failure caused by autoimmune hepatitis manifests as acute to subacute liver injury
.
This type of acute liver failure is often insidious at first and may not be able to get a preliminary diagnosis; such patients often have an elevated globulin ratio and positive autoantibodies.
These features may be absent, so liver biopsy is required.
Confirmed
.
80% of patients with ALF caused by autoimmune hepatitis are women
.
Similar to drug-induced liver injury, ALF caused by autoimmune hepatitis has a poor prognosis and often requires liver transplantation (Table 1)
.
Two-thirds of HBV-induced ALF cases of HBV and HAV are caused by new infections, and the remaining cases are caused by the reactivation of the virus of previously HBV-infected persons under chemotherapy or other immune regulation environments
.
When immune suppression allows viral replication to increase, ALF caused by HBV reactivation occurs, and its prognosis is worse than that caused by new HBV infection
.
HAV infection rarely causes ALF, less than 3% of cases in developed countries cause ALF, and the overall prognosis is also good
.
Summary of the etiology of acute liver failure Figure 1 The etiology of acute liver failure (click the picture to view the larger image) Reference: [1] R ToddStravitz, at al.
Acute liver failure[J].
The Lancet.
September 2019: 869-881.
DOI: https://doi.
org/10.
1016/S0140-6736(19)31894-X[2] Wang Fusheng, et al.
Schiff Hepatology (11th edition) [M].
Peking University Medical Press.
2015.
[3] Wang Yuming.
Interpretation of the 2017 EASL clinical practice guidelines "Acute (Fulminant) Liver Failure Management"[J].
Chinese Journal of Clinical Infectious Diseases, 2017, 10(04):241-249.
The patient has no previous liver disease and is characterized by sudden and severe hepatocyte dysfunction (jaundice, coagulopathy, and encephalopathy)
.
The disease can rapidly progress to coma, leading to death due to cerebral edema and multiple organ failure
.
It is called "syndrome" because ALF has many causes, and the course and prognosis of different causes are different
.
Therefore, determining the cause of acute liver failure is essential for guiding treatment, predicting prognosis, and evaluating whether liver transplantation is needed
.
The five most common causes in developed countries are: paracetamol toxicity, ischemia, drug-induced liver injury, hepatitis B virus, and autoimmune hepatitis.
These causes account for nearly 80% of the total number of cases
.
In contrast, viral hepatitis A, B and E (HAV, HBV, HEV) are the main causes of ALF in developing countries
.
Table 1 Population distribution of different causes of ALF, laboratory test results at admission, and prognosis comparison (data from the American Adult Acute Liver Failure Research Group) Note: Acute liver injury caused by acetaminophen is common in developed countries, and liver is rare in Asian countries Insufficiency of oxygenated blood volume in the ischemic liver has many causes, and leads to hyperacute but self-limiting liver injury, which is characterized by a high concentration of transaminase and a low concentration of bilirubin
.
Except for a few reasons (such as heatstroke and cocaine toxicity), transaminase concentrations greater than 3000 IU/L and bilirubin concentrations less than 5.
0 mg/dL are common in liver ischemia and acetaminophen poisoning (Table 1)
.
An echocardiogram showing a drop in left ventricular ejection fraction indicates ischemia caused by severe heart failure
.
Other causes of poor perfusion include hypotension (shock) caused by decreased blood volume, septic shock, tissue hypoxia (such as respiratory depression caused by opioids), lung failure, and cocaine use
.
In these cases, the incidence of acute kidney injury and acute liver injury are almost the same
.
Although the intravascular volume can be restored and cardiac hemodynamics can be quickly improved, the short-term prognosis of ALF caused by ischemia is good; but if the underlying cause of hemodynamic damage is irreversible, the long-term prognosis is still uncertain
.
Liver ischemic injury rarely requires liver transplantation, unless the cause is direct damage to liver blood circulation (such as hepatic artery embolism)
.
Drug-induced liver injury Specific drug-induced liver injury is the second most common cause of ALF after acetaminophen, and its prognosis is poor
.
Only 10% of patients with drug-induced liver injury have acute liver failure, and there is a possibility of liver transplantation or death
.
This idiosyncratic hepatotoxicity is believed to be based on an immune response, and some individuals are genetically susceptible
.
Antibiotics account for almost 50% of all drug-induced liver injury cases, partly because they are more commonly used and usually at higher doses (ie at least 500-1000 mg per day), which increases the risk of liver injury
.
Compared with viral acute liver failure, there is no specific diagnostic test for drug-induced liver injury
.
Determining a particular drug requires a careful medical history and exclusion of other causes
.
Compared with liver ischemia and acetaminophen, drug-induced acute liver failure is accompanied by lower transaminase concentration and high bilirubin concentration (Table 1)
.
Autoimmune hepatitis Acute liver failure caused by autoimmune hepatitis manifests as acute to subacute liver injury
.
This type of acute liver failure is often insidious at first and may not be able to get a preliminary diagnosis; such patients often have an elevated globulin ratio and positive autoantibodies.
These features may be absent, so liver biopsy is required.
Confirmed
.
80% of patients with ALF caused by autoimmune hepatitis are women
.
Similar to drug-induced liver injury, ALF caused by autoimmune hepatitis has a poor prognosis and often requires liver transplantation (Table 1)
.
Two-thirds of HBV-induced ALF cases of HBV and HAV are caused by new infections, and the remaining cases are caused by the reactivation of the virus of previously HBV-infected persons under chemotherapy or other immune regulation environments
.
When immune suppression allows viral replication to increase, ALF caused by HBV reactivation occurs, and its prognosis is worse than that caused by new HBV infection
.
HAV infection rarely causes ALF, less than 3% of cases in developed countries cause ALF, and the overall prognosis is also good
.
Summary of the etiology of acute liver failure Figure 1 The etiology of acute liver failure (click the picture to view the larger image) Reference: [1] R ToddStravitz, at al.
Acute liver failure[J].
The Lancet.
September 2019: 869-881.
DOI: https://doi.
org/10.
1016/S0140-6736(19)31894-X[2] Wang Fusheng, et al.
Schiff Hepatology (11th edition) [M].
Peking University Medical Press.
2015.
[3] Wang Yuming.
Interpretation of the 2017 EASL clinical practice guidelines "Acute (Fulminant) Liver Failure Management"[J].
Chinese Journal of Clinical Infectious Diseases, 2017, 10(04):241-249.
