Published online Sep 7, 2016. doi: 10.3748/wjg.v22.i33.7595
Peer-review started: January 6, 2016
First decision: January 28, 2016
Revised: March 3, 2016
Accepted: March 30, 2016
Article in press: March 30, 2016
Published online: September 7, 2016
To assess the practice of caring for acute liver failure (ALF) patients in varying geographic locations and medical centers.
Members of the European Acute Liver Failure Consortium completed an 88-item questionnaire detailing management of ALF. Responses from 22 transplantation centers in 11 countries were analyzed, treating between 300 and 500 ALF cases and performing over 100 liver transplants (LT) for ALF annually. The questions pertained to details of the institution and their clinical activity, standards of care, referral and admission, ward- based care versus intensive care unit (ICU) as well as questions regarding liver transplantation - including criteria, limitations, and perceived performance. Clinical data was also collected from 13 centres over a 3 mo period.
The interval between referral and admission of ALF patients to specialized units was usually less than 24 h and once admitted, treatment was provided by a multidisciplinary team. Principles of care of patients with ALF were similar among centers, particularly in relation to recognition of severity and care of the more critically ill. Centers exhibited similarities in thresholds for ICU admission and management of severe hepatic encephalopathy. Over 80% of centers administered n-acetyl-cysteine to ICU patients for non-paracetamol-related ALF. There was significant divergence in the use of prophylactic antibiotics and anti-fungals, lactulose, nutritional support and imaging investigations in admitted patients and in the monitoring and treatment of intra-cranial pressure (ICP). ICP monitoring was employed in 12 centers, with the most common indications being papilledema and renal failure. Most patients listed for transplantation underwent surgery within an average waiting time of 1-2 d. Over a period of 3 mo clinical data from 85 ALF patients was collected. Overall patient survival at 90-d was 76%. Thirty six percent of patients underwent emergency LT, with a 90% post transplant survival to hospital discharge, 42% survived with medical management alone.
Alongside similarities in principles of care of ALF patients, major areas of divergence were present in key areas of diagnosis, monitoring, treatment and decision to transplant.
Core tip: Acute liver failure is rare, but carries high mortality and resource use. Standard of care and clinical practice varies between centers. In a survey conducted among members of the European-Acute-Liver-Failure consortium we have identified similarities in principles of care, including basic clinical management, recognition of severity and care of critically ill patients. Major areas of divergence were pre-intensive care unit (ICU) care and elements of ICU care. Further research is required regarding intra-cranial pressure monitoring and therapy, prophylactic antibiotics and anti-fungals, and liver support systems; we also identified a great need for improving prognostic evaluation for liver transplantation and refinement of transplantation criteria.