CHRONIC LIVER DISEASE AND LIVER FAILURE


I. "Child-Pugh Classification" of liver disease severity

1 points2 points3 points
AscitesNoneSlightModerate or greater
Serum bilirubin (in mg/dL)< 22-3> 3
Serum albumin (in mg/dL> 3.52.8-3.5< 2.8
INR< 1.71.8-2.3> 2.3
EncephalopathyNoneGrade 1-2Grade 3-4

5-6 points = "Class A-Well-compensated"
7-9 points = "Class B-Significant functional compromise"
10-15 = "Class C-Decompensated disease"

II. Acute liver failure
  1. In a study in 173 adults with acute liver failure not due to acetaminophen overdose randomized to N-acetylcysteine vs. placebo, there was no sig. diff. in overall survival at 3wks, but for pts with coma grades I-II, transplant-free survival at 1y was sig. higher in the N-acetylcysteine group (52% vs. 30%) (Gastroent. 137:856, 2009-JW)
III. Hepatic encephalopathy
  1. Characterized by neuropsychiatric sx; all the way from subtle personality changes to focal neurologic signs to frank coma
  2. Associated with either acute or advanced chronic liver disease
  3. Management
    1. Antibiotics often used; thought to work by reducing ammonia-producing colonic bacteria (e.g. neomycin, ribostamycin, vancomycin, or rifaximin)
    2. Lactulose, to acidify the colonic lumen and reduce ammonia absorption
      1. Lactulose not found to be ass'd with significant improvement in encephalopathy sx or mortality in a meta-analysis of 22 randomized trials and ass'd with significantly worse changes in encephalopathy sx compared with antbiotics (BMJ 328:1046, 2004--JW)
IV. Hepatorenal syndrome
  1. A complication of end-stage liver disease, often lethal
  2. Mean survival is 1.7wks from diagnosis
  3. Only effective tx as of 2006 is liver transplantation
  4. In an uncontrolled study in 20 patients with hepatorenal syndrome treated with a regimen of albumin IV (to maintain central venous pressure at > 3cm H2O) + furosemide (titrated to maintain urine output > 50cc/h); incidence of response (CrCl rising to > 40mL/min) occurred in 11 pts (Am. J. Gastroent. 100:2702, 2005--JW)