Mistakes in ... Booklet 2020 - 17

ueg education

a patient who has no pre-existing chronic
liver disease.8 ALF is characterized by the
development of both coagulopathy (INR >1.5)
and hepatic encephalopathy. The condition of
patients who develop coagulopathy, but not
hepatic encephalopathy, is defined as acute liver
injury (ALI).
The clinical course of ALF usually starts with a
severe ALI. The ALI is characterized by a 2-3-fold
elevation of transaminase levels, associated
with impaired liver function (jaundice and
coagulopathy), in a patient with no prior
evidence of liver disease. Considering
jaundice as the first sign, 'hyperacute liver f
ailure' describes patients who develop hepatic
encephalopathy within 7 days, 'acute liver
failure' describes patients who develop hepatic
encephalopathy between 8 and 28 days, and
'subacute liver failure' describes patients who
develop hepatic encephalopathy within
5-12 weeks.
These ALF phenotypes have distinct
presentations and prognosis.8 Patients with
a hyperacute presentation have severe
coagulopathy, extremely elevated transaminase
levels, and only moderate (if any) increase in their
bilirubin levels.67,68 By contrast, patients who have
a subacute presentation have a severe jaundice,
mild-to-moderate coagulopathy, and only a mild
increase in transaminase levels. These patients
frequently have splenomegaly and ascites, and
a shrinking liver viewed on imaging. Hepatic
encephalopathy occurs very late, and is often a
manifestation of bacterial infection. Once hepatic
encephalopathy occurs, these patients have a
very short window, if any, in which to undergo
liver transplantation.69
In ALF, early identification of patients who
will not survive with medical support alone is of
utmost importance, as they will be priority
candidates for liver transplantation. Even at an
early stage, there are clinical features (i.e.
development of hepatic encephalopathy) that
may be helpful for risk stratification. As a general
rule, the development of hepatic encephalopathy
prompts critical care assessment and transfer to
a transplant centre.8
The adoption of a single threshold of hepatic
encephalopathy severity across the three
phenotypes of ALF does, however, seem too
simplistic. In patients with a subacute
presentation, even low-grade hepatic
encephalopathy may indicate poor prognosis,
whereas survival with medical support may
be excellent in the hyperacute setting with
concomitant hepatic encephalopathy of equal
severity. Recent proposals suggest that, in an
appropriate clinical context accompanied
by a decreasing liver volume, super urgent
listing could be undertaken in patients with
subacute liver failure even without the
presence of clinically overt hepatic
encephalopathy.8

Mistakes in... 2020

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