Patient handout

Acute Liver Failure

PRODUCTION

1. Your condition

This handout is for acute liver failure. Your care team identified this based on: inr >=1.5 in patient without known chronic liver disease (aasld alf).

Other reasons your team may use this plan: new-onset hepatic encephalopathy / altered mental status (aasld alf); rapid-onset jaundice + coagulopathy in previously healthy patient (stravitz lee 2019); known or suspected acetaminophen overdose (aasld alf).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
acetylcysteine	150 mg/kg IV in D5W over 60 min, then 50 mg/kg over 4h, then 100 mg/kg over 16h (21h Prescott protocol); continue 6.25 mg/kg/h until INR <1.5 or transplant or death	IV	continuous infusion	AASLD ALF Class I for APAP; Lee 2009 (Gastroenterology PMID 19524577) demonstrated transplant-free survival benefit in non-APAP ALF coma grades I-II

Plan: Acute liver failure - NAC for all + etiology-specific therapy + cerebral edema bundle (AASLD ALF + Stravitz Lee 2019)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Kings College APAP criteria: arterial pH <7.30 after adequate resuscitation OR (INR >6.5 AND Cr >3.4 mg/dL AND HE grade 3-4) (OGrady 1989)(life-threatening)
Kings College non-APAP: INR >6.5 OR any 3 of (age <11 or >40, non-A/non-B/DILI, jaundice-to-HE >7d, INR >3.5, bilirubin >17.5 mg/dL) (OGrady 1989)(life-threatening)
HE grade 4 (coma, posturing, papilledema) OR arterial NH3 >150 micromol/L OR herniation signs (Bernal Wendon 2013)(life-threatening)
Arterial lactate >3.0 mmol/L 12h post-fluid resuscitation OR >3.5 mmol/L early in APAP ALF (Bernal 2002)(life-threatening)
Glucose <70 mg/dL despite D10 infusion (Stravitz Lee 2019)
Hemolytic Coombs-negative anemia + ALP:bili ratio <4 + AST:ALT >2.2 in patient <40yo (Korman 2008)(life-threatening)
Pregnant patient with ALF (AFLP, HELLP, eclamptic liver) (Stravitz Lee 2019)(life-threatening)

5. Follow-up

Survivors: hepatology follow-up; counseling on hepatotoxin avoidance (APAP <2 g/day if at-risk; alcohol abstinence); LiverTox reporting for DILI; vaccinations (HAV/HBV/influenza/pneumococcal); transplant recipients per transplant center protocol (Stravitz Lee 2019)

6. Sources

Guideline: AASLD Position Paper: The Management of Acute Liver Failure (Polson Lee 2005) + Stravitz Lee Lancet Acute Liver Failure 2019 (current floor; AASLD ALF Guidance 2023 web update in progress)