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For further information, see CMDT Part 18-05: Acute Liver Failure
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Essentials of Diagnosis
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General Considerations
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Acute liver failure may occur after reactivation of hepatitis B in carriers who receive immunosuppressive therapy
In fulminant liver failure, encephalopathy and coagulopathy (international normalized ratio [INR] ≥ 1.5) develop within 8 weeks after the onset of acute liver injury
Subfulminant liver failure occurs when encephalopathy and coagulopathy appear between 8 weeks and 6 months after the onset of acute liver injury
Acute-on-chronic liver failure
Refers to acute deterioration in liver function and associated failure of other organs in a person with preexisting chronic liver disease
Often precipitated by bacterial infection or an alcohol binge and alcohol-associated hepatitis
Acetaminophen toxicity accounts for 45% of cases; idiosyncratic drug reactions are second most common
Among cases caused by acetaminophen
The risk of acute liver failure is increased in patients with diabetes mellitus, and outcome is worsened by obesity
Viral hepatitis accounts for only 12% of all cases of acute liver failure, due in part to universal vaccination of infants and children against hepatitis B and the availability of the hepatitis A vaccine
Hepatitis C is a rare cause of acute liver failure in the United States, but acute hepatitis A or B superimposed on chronic hepatitis C may cause acute liver failure
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Acetaminophen toxicity
Idiosyncratic drug reactions (eg, antibiotics, antituberculosis drugs, antiepileptics, and a marked increase in cases due to herbal and dietary supplements since 1995)
Mushroom poisoning (Amatoxins)
Viruses (hepatitis A, B, C, D, E, CMV, EBV, HSV, parvovirus B19, influenza virus, yellow fever virus, Middle East respiratory syndrome virus, Ebola virus, SARS coronavirus)
Shock
Heat stroke
Budd-Chiari syndrome
Malignancy (especially lymphomas)
Wilson disease
Reye syndrome
Fatty liver of pregnancy and other disorders of fatty acid oxidation
Autoimmune hepatitis
Grand mal seizures (rarely)
Cause is indeterminate in approximately 5.5% of cases
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An estimated 1600 cases of acute liver failure occur each year in the United States
In endemic areas, hepatitis E is an important cause of acute liver failure, particularly in pregnant women
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Gastrointestinal symptoms (nausea, vomiting, anorexia)
Jaundice may be absent or minimal early
Systemic inflammatory response
Acute kidney injury
Clinically significant bleeding is uncommon and reflects severe systemic inflammation rather than coagulopathy
Severity of extrahepatic organ dysfunction (as assessed by the Sequential Organ Failure Assessment [SOFA]) correlates ...