Management of liver failure Prof. Anupam Sibal Group Medical Director, Apollo Hospitals Group Adjunct Professor of Paediatrics School of Medicine University of Queensland, Brisbane, Australia Senior Consultant Pediatric Gastroenterologist and Hepatologist Apollo Centre for Advanced Pediatrics Indraprastha Apollo Hospital Dr. Akshay Kapoor Pediatric Gastroenterologist and Hepatologist Apollo Centre for Advanced Pediatrics Indraprastha Apollo Hospital April 2012
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Management of liver failure
Prof. Anupam SibalGroup Medical Director, Apollo Hospitals Group
Adjunct Professor of PaediatricsSchool of Medicine
University of Queensland, Brisbane, AustraliaSenior Consultant
Pediatric Gastroenterologist and HepatologistApollo Centre for Advanced Pediatrics
Indraprastha Apollo Hospital
Dr. Akshay KapoorPediatric Gastroenterologist and Hepatologist
Apollo Centre for Advanced PediatricsIndraprastha Apollo Hospital
April 2012
Fulminant hepatic failure
Onset of altered mental status within 8 weeks of initial symptoms in an otherwise healthy individual with no previous history of liver disease
Trey and Davidson, N Engl J Med 1968
April 2012
Classification
Hyper acute: within 1 week of onset of symptoms
Acute: between 8 days - 28 days
Sub acute: between 29 days to 12 weeks
O’grady et al, Lancet 1993
April 2012
Definition of ALF
“evidence of coagulation abnormality, usually an INR >1.5, and any degree of mental alteration (encephalopathy) in a patient without pre-existing cirrhosis and with an illness of < 26 weeks duration”
AASLD position paper on ALF, 2005
April 2012
ALF definition in children
Biochemical evidence of acute liver injury
Hepatic-based coagulopathy defined as PT ≥ 15 seconds or INR ≥ 1.5 not corrected by vitamin K in the presence of clinical hepatic encephalopathy (HE) or PT ≥20 seconds or INR ≥ 2.0 regardless of the presence or absence of clinical HE
No known evidence of chronic liver disease
PALF study group J pediatric 2006
April 2012
Prevention of complications
Management of complications
Liver transplantation
April 2012
Medication
PPI, H2 blockers
Antibiotics
Mannitol
Lactulose
N-acetylcysteine
AASLD position paper on ALF, 2005
April 2012
diaFLUX dialyzer
April 2012
LT - key questions
Is there a chance of spontaneous recovery?
Is a transplant feasible?
Have irreversible complications occurred?
April 2012
King’s criteria for LT non-paracetamol causes
PT > 100 sec
Or 3 of the following :
Bilirubin >17.5 mg%
Age < 10 or > 40
PT > 50 sec
Symptoms to encephalopathy > 7 days
NANB or drug induced
O'Grady et al 1989
April 2012
FHF – King’s criteria for LT paracetamol overdose
pH < 7.3
or the following three factors :
PT > 100 secs
Creatinine > 3.5 mg/dl
Grade III or IV encephalopathy
O'Grady et al 1989
April 2012
INR ≥ 4
Bilirubin ≥ 13.8 mg/dl
Age < 2 yr
WBC > 9 X 109 / l
INR > 4
90 % correctly classified
Dhawan et al Pediatr transplant, 2011
April 2012
Apollo experience
INR > 4
April 2012
Chronic liver failure
No accepted definition
Associated with development of cirrhosis and its complications – malnutrition, PHT, bleeding esophageal varices, ascites, encephalopathy, HRS