Acute Liver Failure


  • Sepsis/shock, viral (HBV) heatstroke, lymphomatic infiltration, Budd-Chiari, toxins (i.e. acetaminophen), ETOH, ischemic hepatopathy, Wilson’s
    • Immunocompromised: HSV, CMV, EBV, VZV
  • Opiates such as oxycodone may slow gut transit leading to increased toxicity of acetaminophen at lower doses than expected


  • Hepatic encephalopathy (Grade 1 (disordered sleep) through Grade 4 (coma))
    • Tx: lower ICP
      • Hyperosmotic agents (mannitol, hypertonic saline), hyperventilation, hypothermia
      • Lactulose NOT EFFECTIVE in hepatic encephalopathy 2/2 ALF
      • NAC – best used w/ Grade 1-2 hepatic encephalopathy
  • Infection – leading cause of death in ALF
    • Prophylactic abx debatable

Antivirals for HBV ALF

  • Lamivudine – use if tx duration expected to be short
  • Entecavir/tenofovir (more potent agents) – better used for severe, protracted HBV course (defined by increased INR & jaundice x 4 weeks)



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