Acute liver failure: a European perspective

Introduction

Acute liver failure (ALF) is a rare disease with a spectrum of presentations from mild coagulopathy and altered conscious level to multiple organ failure and intracranial hypertension (ICH). A new group, Acute Liver Failure studies in Europe (ALSiE), has and wishes to further initiate collaboration between centres with clinical expertise in the management of ALF. It aims to establish a pan-European database of clinical and demographic data in ALF and initiate clinical studies.

Methods

We describe the experience of 13 centres in seven countries over a 3-month period to 31 March 2009. ALF was defined as an INR >1.5 and encephalopathy in the absence of chronic liver disease. Results are presented as median and IQ range.

Results

Eighty-five patients were treated, acetaminophen was the dominant aetiology in the UK, 60%, and represented 34% in other centres. At presentation INR was 3.8 (2.1 to 6.5), hepatic encephalopathy (HE) grade I (0 to 2) was observed and 20% required pressors. Grade III/IV coma was seen in 64% during their course and of these 25% developed ICH. Seventy-one per cent required ventilation, 58% renal replacement therapy and pressors in 65%. Ninety per cent required management in a critical care environment. Overall survival was 75% - 42 cases fulfilled poor prognostic criteria (PPC), of whom 31 were transplanted, 28 (90%) surviving to hospital discharge. Of the 11 remaining, four survived and seven died. Thirty-two out of 43 who did not fulfill PPC survived. Patients who died were older and had a predominant aetiology of hypoxic hepatitis. One organ support or less was associated with 70% survival with medical management alone. Two organ support or more was required in 55 patients and 27% survived with medical management, the remainder requiring transplantation or died.

Conclusions

ALF has a high prevalence of progression to multiple organ failure requiring a multidisciplinary approach (critical care, transplant surgery and hepatology) to achieve optimal outcome. The development of ICH is 25% in grade III/IV HE. Despite this, outcomes are good.