Moffitt BONUS M&M PEARLS 9/23: Acute liver failure

Acute liver failure:

  • 3 criteria for diagnosis:
    • INR >1.5 (new)
    • Encephalopathy (usually last)
    • No pre-existing liver disease (look on exam for stigamata of liver dz, careful history)
  • Most common cause of death is neurological complications (edema and herniation). Hyperammonemia crosses the BBB and gets stuck, pulls in fluid and causes cerebral edema. Should go to the ICU for q1-2hr neuro checks, may need hypertonic saline and mannitol (targeted to Na 145 or Serum osm 320)
  • Differential for ALT >1000 is short with three main things: toxin (Tylenol, mushroom), ischemia, viral hepatitis


  • Useless in end stage liver disease for hepatic encephalopathy. Must be made as a clinical diagnosis
  • In acute liver failure, ammonia can predict prognosis (cerebral edema). Cutoff of >100 suggests poor prognosis.


  • Good for almost every cause of ALF except drug-induced. Most data for Tylenol but growing evidence for other causes of ALF. Mostly harmless therapy but should be aware of the following:
    • Volume considerations (often cerebral edema etc, so if no benefit then may not want the extra volume)
    • Infusion-related (vasodilation, pulm edema)

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