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For further information, see CMDT Part 16-16: The Liver in Heart Failure

Key Features

  • Ischemic hepatopathy is also known as shock liver or acute cardiogenic liver injury (correctly reflecting its origin in transient poor perfusion) and sometimes called ischemic hepatitis or hypoxic hepatitis (terms that are partly correct in reflecting its origin in ischemia or hypoxia but partly incorrect in that there is no infiltration of acute inflammatory cells)

  • Caused by an acute fall in cardiac output (eg, acute myocardial infarction, arrhythmia, or septic or hemorrhagic shock)

  • Usually occurs in a patient with passive congestion of the liver

  • May affect up to 2.5 of every 100 patients admitted to an intensive care unit

  • Rare cases have occurred in patients with COVID-19

Clinical Findings

  • Typically follows hypotension, but clinical hypotension may not be noted

  • Precipitating event can be arterial hypoxemia due to

    • Respiratory failure

    • Sleep apnea

    • Severe anemia

    • Heat stroke

    • Carbon monoxide poisoning

    • Cocaine use

    • Bacterial endocarditis

  • In severe cases, encephalopathy may develop

  • Mortality rate is high, resulting from the underlying disease

  • In patients who recover, elevated aminotransferase levels return to normal quickly, usually within 1 week, in contrast to viral hepatitis

  • In chronic passive congestion

    • Hepatojugular reflux is present

    • With tricuspid regurgitation, the liver may be noted to be pulsatile on palpation

  • Ascites may be out of proportion to peripheral edema in patients with right-sided heart failure


  • Hallmarks of ischemic hepatopathy

    • Rapid marked elevation (often > 5000 units/L) of serum aminotransferase levels (eg, alanine aminotransferase [ALT])

    • Early rapid rise in serum lactate dehydrogenase (LD) level (with an ALT-to-LD ratio < 1.5)

    • Elevations of serum alkaline phosphatase and bilirubin are usually mild, but jaundice is associated with worse outcomes

    • Liver stiffness measurement by elastography is increased even in the absence of fibrosis

    • Prothrombin time may be prolonged

  • In passive congestion of the liver ("nutmeg liver") caused by right-sided heart failure

    • Serum bilirubin level may be elevated, occasionally as high as 40 mg/dL (684 mcmol/L), resulting partly from hypoxia of perivenular hepatocytes

    • Serum alkaline phosphatase levels are normal or slightly elevated

    • Aminotransferase levels are only mildly elevated in the absence of superimposed ischemia

  • Ascites caused by heart failure generally has

    • High serum ascites-albumin gradient (> 1.1)

    • Protein content of more than 2.5 g/dL


  • Supportive

  • Treat underlying cardiac disease

  • Treat precipitating arterial hypoxemia

  • Statin therapy may protect against ischemic hepatopathy

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