Liver Failure

What the liver does

The liver makes clotting factors and proteins, clears toxins and drugs, stores energy, produces bile to digest fat, and helps fight infection. In liver failure, these functions break down:

• clotting factors fall, causing bleeding and bruising
• toxins such as ammonia build up, affecting the brain (hepatic encephalopathy)
• bilirubin builds up, causing jaundice
• albumin falls, contributing to fluid buildup
• blood sugar regulation fails, causing low blood sugar
• infection risk rises

Types of liver failure

Causes

Acute liver failure

• Acetaminophen (paracetamol) toxicity: the leading cause in the US, from intentional overdose or taking too much over several days, often from multiple products containing acetaminophen
• Drug-induced liver injury from antibiotics, anti-seizure medicines, herbal and dietary supplements
• Viral hepatitis: hepatitis A, B, E; herpes viruses rarely
• Autoimmune hepatitis and Wilson disease
• Pregnancy-related: acute fatty liver of pregnancy, HELLP syndrome
• Poor blood flow to the liver (shock liver)
• Toxins: Amanita mushrooms

Chronic liver failure

• cirrhosis from alcohol-related liver disease
• fatty liver disease linked to obesity and diabetes
• chronic hepatitis B and C
• primary biliary cholangitis, primary sclerosing cholangitis
• hemochromatosis, alpha-1 antitrypsin deficiency

Symptoms

Early

• fatigue and weakness
• nausea and loss of appetite
• abdominal discomfort
• itching

Advanced

• jaundice: yellow skin and eyes, dark urine
• confusion, sleepiness, personality changes, hand tremor (encephalopathy)
• easy bruising and bleeding
• swollen belly (ascites) and leg swelling
• vomiting blood or black stools from bleeding varices
• reduced urine (kidney involvement)
• muscle wasting

Diagnosis

• Blood tests: liver enzymes (ALT, AST), bilirubin, albumin, INR (clotting time; an INR of 1.5 or more with encephalopathy defines acute liver failure), blood count, glucose, kidney function, ammonia
• Acetaminophen level, toxicology screen
• Viral hepatitis and autoimmune tests, ceruloplasmin (Wilson disease)
• Ultrasound with Doppler to look at the liver, blood flow and fluid
• Liver biopsy in selected cases
• MELD score: combines bilirubin, INR, creatinine and sodium to estimate severity and prioritize transplant

Treatment

Acute liver failure

• Intensive care at a transplant center
• N-acetylcysteine (NAC): the antidote for acetaminophen toxicity, most effective within 8 hours of overdose; also used in some non-acetaminophen cases
• Specific treatments: antivirals for hepatitis B, steroids for autoimmune hepatitis, delivery for pregnancy-related causes
• Supportive care: managing brain swelling, infections, kidney failure, blood sugar and bleeding
• Urgent liver transplant when the liver is unlikely to recover

Chronic liver failure

• Stop the cause: alcohol abstinence, antiviral treatment for hepatitis B or C, weight loss for fatty liver disease
• Ascites: salt restriction, diuretics, draining fluid (paracentesis)
• Hepatic encephalopathy: lactulose and rifaximin
• Varices: beta-blockers and endoscopic banding
• Nutrition: adequate protein and calories; frequent small meals and a late-evening snack
• Liver cancer screening with ultrasound every 6 months
• Vaccinations for hepatitis A and B, flu and pneumonia
• Liver transplant evaluation for decompensated cirrhosis

Medicines to avoid

People with liver disease should avoid NSAIDs, sedatives, alcohol and unregulated supplements. Acetaminophen at reduced doses (often up to 2 grams a day) is usually the safest pain reliever, but check with your doctor.

Outlook

Acute liver failure from acetaminophen has a relatively good chance of spontaneous recovery with prompt NAC and intensive care. Other causes more often need transplant. Survival after liver transplant is about 85 to 90% at 1 year. In chronic liver failure, outlook depends on the MELD score, complications and whether the underlying cause can be stopped.

Prevention

• Never exceed the acetaminophen label dose, and check all medicine labels for acetaminophen
• Limit alcohol, or stop entirely if you have liver disease
• Get vaccinated against hepatitis A and B, and tested for hepatitis C
• Keep a healthy weight and control diabetes
• Avoid sharing needles, razors or toothbrushes
• Use herbal supplements cautiously

Frequently asked questions

What are the first signs of liver failure?

Early signs are often vague: tiredness, nausea, loss of appetite and abdominal discomfort. Later signs include yellowing of the skin and eyes, confusion, easy bruising or bleeding, a swollen belly and dark urine. Confusion with jaundice is an emergency.

What is the most common cause of acute liver failure?

In the US and many Western countries, acetaminophen (paracetamol) overdose is the most common cause, either intentional or from accidentally taking too much over several days. Viral hepatitis is the leading cause in many other parts of the world.

Can the liver recover from liver failure?

Sometimes. In acute liver failure, especially from acetaminophen, the liver can regenerate if the person survives the critical period. In chronic liver failure, scarring is mostly permanent, but stopping the cause can stabilize it. Many need a liver transplant.

How long can you live with end-stage liver disease?

It varies widely. The MELD score helps predict survival: people with higher scores have a shorter outlook without transplant. Complications such as ascites, bleeding and encephalopathy indicate advanced disease. Transplant offers good long-term survival for suitable candidates.

What happens if you take too much acetaminophen?

An overdose may cause few symptoms for the first 24 hours, then liver damage can develop over 2 to 4 days. Treatment with N-acetylcysteine is very effective if started early. Seek emergency care or call Poison Help immediately after any suspected overdose.