A person who leads a normal life, who is not known to have a liver disease previously, abruptly develops yellowing of eyes and urine, vomiting, clouding of thought processes and sinks into coma. This is the dreadful syndrome of Acute liver failure (ALF) .This a life-threatening illness, where a previously normal liver fails within days to weeks. On top of more than 500 vital functions which liver performs, including filtering, cleansing, manufacturing and digestive functions it performs- all of these come to a standstill in acute liver failure. Sudden loss of synthetic and detoxification function of liver results in jaundice, brain dysfunction, bleeding due to blood clotting mechanisms, and multiorgan failure. Literally a LIVER ATTACK or “ Harthal of liver” !
Public is aware of what heart attack is all about- ALF is liver attack , probably has much more drastic downhill course than heart attack if left untreated or suboptimaly treated.
Viruses :– Common causes are infection with liver directed viruses(Hepatotropic viruses)- Hepatitis B virus, Hepatitis A virus and Hepatitis E virus being common in India. Rarely viruses which cause chicken pox can induce acute liver failure , so are viruses like Herpes simplex virus(HSV) and Cytomegalo virus(CMV).
Drug-Induced Liver Injury :– This can happen with many medicines. Antituberculous medicines, cholesterol lowering medicines(statins), Methotrexate used in skin disorderes, cancer chemotherapeutic agents are few among many .All medicines prescribed in modern medicine are put through varuious phases of drug trials , so that by the time the medicine is marketed , the side effects expected are also known. If a medicne is known to have liver toxicity, the prescribing doctor keeps this in mind and orders Liver function test (LFT) periodically. This is to facilitate remedial measures early if at all liver gets a hit.
Herbal therapy-induced liver injury (HILI) :– this is a growing problem in India, where Herbal remedies are marketed without passing through drug trials or safety check. These so called over the counter natural/herbal remedies are known to cause liver failure.
Poisonings :– mostly suicidal attempts- Paracetamol commonly used for treating fever is readily avialble in house holds and happens to be a very common cause of liver failure following suicidal attempts.Any medicine for that matter taken overdose wilfully can result in Liver damage and failure. Zinc phosphide used as Rat killer is a common poisoning in Tamil nadu- in cities as well as suburbs.Mushroom poisonings are known to occur(Amanita Phalloides), but are much less common in this part of the country.
Alcohol :– Excessive use of alcohol, particularly binge drinling pattern can reesult in Alcoholic Hepatitis and liver failure.Many a time this acute insult and inflammation occur in the background of preexisting liver scarring( Fibrosis) . Alcoholic hepatitis has extremely high mortality without prompt treatment.
Pregnancy-associated Liver Disease :– Acute liver failure can occur in the setting of pregnancy, a condition called Acute Fatty Liver Disease of pregnancy(AFLD). Early delivery of the baby and prompt liver supportive measures to be instituted. Liver transplantaion may be indicated in some cases.
The major challenge in successful treatment of Acute liver failure is the peculiar hyperdynamic natural history this illness has. It is a rapid cascade of events and liver failure and multiorgan failure happens minute by minute or hour by hour. Once jaundice occurs, the liver failure progresses quickly and results in failure of other organs especially the brain in few days to a week or two. In this short span of events, before permanent damage sets in to other organs, especially brain, reaching a full fledged liver care facility is the major challenge. Medical management is possible with prompt intensive liver care in select situations ( based on the cause of ALF and extent of liver insult). Many patients require liver transplantation to come back to life.
Because ALF often involves rapid deterioration of mental status and the potential for multiorgan failure, patients should be managed in an Intensive liver therapy unit(ILTU). For patients admitted in a non transplant center, the possibility of rapid progression of ALF makes early consultation with a transplant facility critical. Accordingly, plans for transfer to a transplant center should begin in patients with any sort of abnormal mentation. Early institution of antidotes or specific therapy, Liver dialysis and plasma purification techniques may prevent the need for liver transplantation and reduce the likelihood of poor outcome after transplant.
MODES OF TREATMENT AVAILABLE:
Medical Management: This should happen in a dedicated liver intensive care unit, supportive care to liver and the organs which may get damegd in ALF especillay the brain. Specific antidotes are available for select cases like paracetamol poisoning, Viral hepatitis B,autoimmune hepatitis.
Plasma Purification Techniques: Once ALF sets in there is spill over of inflammatory mediators into blood plasma which damage other organ systems.Therapeutic plasma exchange and plasmapheresis are helpful in certaion situations
Liver Dialysis: MARS dialysis serves as a stabilisation technique and as well as a bridge to transplant untill new liver is available from dead organ donation pool
Regenerative Hepatology: liver has immense power to regenerate and during ALF, bone marrow supplies stem cells to the ailing liver to recuperate.There are special regenerative techniques to facilitate this.
Liver Transplantation: If medical management fails or when there are clear pointers in lab tests and clinical feartures which would tell us that medical management wont be efficacious, then urgent liver transplantaion is the way to go.In Indian scenario, lots to be done at this end, especially promotion of cadaveric donation. Thanks to the government appointed body, Tamil Nadu Network of Organ Sharing (TNOS), the state of Tamil Nadu is way ahead of other Indian states in dead donation rates; but issues specific for “Liver attack”, like facilitating Green corridor for transfer of ALF patients from refferal center to advanced liver care facility still remain , so is the case of green corridor facility for organs destined for acute liver failure patients.