Acute liver failure

Overview

Acute liver failure (ALF) is sudden, severe liver damage occurring in people with no prior history of liver disease. When this happens, the liver can no longer perform critical functions, including removing toxins from the body and stabilizing blood sugar levels. People with ALF become sick quickly – often in one week or less – and need immediate medical attention. If untreated, the condition can be fatal.

Though more common in adults, ALF can also affect babies, children and adolescents. In up to half of cases, the cause of the condition is unclear. Known causes of ALF include:

• Medication overdose or reaction. Acetaminophen poisoning is the most frequent cause of ALF in the United States. Other medications, such as valproic acid and isoniazid, can also trigger liver failure.
• Infections. These include herpes simplex virus, several forms of viral hepatitis and other viruses that attack the liver.
• Toxins. Ingesting certain wild mushrooms, insect or weed killers, or cleaning products can kill liver cells or damage the bile ducts, leading to rapid liver failure.
• Metabolic and immune disorders. In some cases, ALF results from protein metabolism disorders, Wilson disease (a disorder where copper builds up in the body), autoimmune hepatitis, or other conditions that can damage the liver.

This rare condition affects an estimated 2,000 people per year in the United States.

Signs and symptoms

Early symptoms of ALF may resemble common childhood illnesses such as the flu. These include:

• Fatigue and malaise (a general feeling of being unwell)
• Nausea or vomiting
• Abdominal pain
• Loss of appetite

As the disease progresses, it can affect processes throughout the body, including in the brain. Signs that the liver is failing include:

• Yellowing of the skin and whites of the eyes (jaundice)
• Swollen abdomen caused by fluid buildup
• Bruising or bleeding easily
• Dark or amber-colored urine
• Confusion or inattention
• Irritability
• Sleep problems such as daytime sleepiness or nighttime insomnia

Diagnosis

Your child's doctor will start by collecting details about medical history and conducting a physical exam. This can help pinpoint a potential cause of the ALF, such as an acetaminophen overdose or a recent infection. The exam may include tests of your child's mental state to check for brain dysfunction, a condition known as encephalopathy.

Blood and urine tests also help assess liver damage. These tests look for:

• High levels of bilirubin (produced by the normal breakdown of red blood cells, this substance is excreted from the body when the liver is healthy)
• High levels of certain liver enzymes
• Problems with coagulation (blood clotting)
• Other changes in the body that may indicate a common cause of ALF

The doctor may also order an abdominal ultrasound or a liver biopsy to check the condition of the liver look for the cause of the ALF.

Treatment

Many patients with ALF can make a full recovery with medical supervision and the use of certain medications. If the liver is not recovering or it is so severely damaged that ALF is causing problems with the brain or other organs, your child may need a liver transplant.

Finding the cause of ALF can help determine what approach is needed, but doctors can't always predict how patients will respond to treatment. Getting treatment in a hospital that offers comprehensive care, including liver transplantation, can help ensure the best outcomes for patients with ALF.

Medications

If ALF is caused by acetaminophen poisoning, an antidote called N-acetylcysteine (NAC) can help restore healthy liver function, especially if started within 12 hours of the overdose. NAC may also help treat ALF stemming from other causes.

Other medications may be used to address the root cause of the ALF and reduce further liver damage. These include:

• Steroids to treat autoimmune hepatitis
• Antiviral therapy to treat viral hepatitis
• Drugs that lower copper levels to treat Wilson disease

Medical supervision

Children with liver failure require close observation and support, often in the hospital's intensive care unit. In the hospital, your child's doctor will manage symptoms of ALF and work to prevent complications. This can include:

• Providing medicine to relieve nausea and abdominal pain, prevent severe bleeding or seizures and reduce swelling in the brain
• Administering IV fluids to treat nutritional deficiencies
• Collecting blood and urine samples to screen for new infections

Liver transplantation

If ALF cannot be reversed with medications and medical supervision, your child may need a liver transplant. Your child may receive a healthy liver from a deceased donor or receive part of the organ from a living donor. Because patients with ALF need treatment urgently, they are given very high priority for a donated liver.