Acute liver failure is a rare presentation to Emergency Departments in the UK, leading to around 400 admissions per year.
Paracetamol overdose accounts for in excess of 70% of cases in the UK, whereas viral hepatitis is the most common cause worldwide. Mortality is exceptionally high and ranges from 60-90%. Paracetamol and hepatitis A have a better prognosis compared to other causes.
Medical treatment of acute liver failure is successful in around 10-40% of cases, dependent on the exact aetiology. However, with transplantation the overall survival rate increases to around 65-70%.
Patients may also present with a decompensation of chronic liver failure and this can be caused by a range of pathologies including alcohol excess.
Studies from the United States estimate that the prevalence of acute kidney injury is about 5% in hospital patients. The incidence of community acquired acute kidney injury has not been defined.
The incidence of acute kidney injury in patients who are critically ill may be as high as 67.2% and the mortality rate in patients admitted to intensive care units who need renal replacement therapy has been reported at 50%.
It has been estimated that up to 30% of hospital acquired acute kidney injury (h-AKI) could be prevented with obvious benefits to patients and the National Health Services.
Liver failure and renal failure can co-exist, in particularly in the generation of new renal dysfunction in those with impaired liver function: the hepato-renal syndrome. Some estimates say that this syndrome occurs in up to 40% of those who have cirrhosis and ascites as part of the natural history of the disease.
Due to the time-sensitive potential reversibility and high mortality rate of these two conditions it is extremely important for an emergency physician to recognise, assess, manage and appropriately refer this patient group.
Remember: After identifying liver or renal failure, always consider the following causes:
- Paracetamol Poisoning
- Biliary Disease
LEARNING OUTCOMES FROM COMPLETING THE TASKS
Recognise the jaundiced and oliguric patient.
Describe the common causes of oliguria.
Describe the common causes of jaundice.
Be able to assess and provide initial management to a patient with hepatic encephalopathy.
LEARNING OUTCOME FROM FACE-TO-FACE TEACHING
Demonstrate how to assess the oliguric patient.
Construct appropriate management plans for the emergency presentations of acute renal failure.
Construct appropriate management plans for the emergency presentations of acute liver failure.
Assess when to refer for specialist advice.
Complete the following before the face-to-face session:
TASK 1: Adding Insult to Injury
Duration: 10 mins
Following the NCEPOD’s review into acute kidney injury called “Adding Insult to Injury” acute kidney injury has become extremely topical. This short video is a good overview of this topic and should refresh some key concepts.
There are many more excellent videos on AKI here.
TASK 2: ACute Kidney Injury (AKI)
Duration: 25 mins
Read the Life In the Fast Lane entry on Acute Kidney Injury (AKI) which provides a good summary of risk factors, causes, consequences and management including indications for Renal Replacement Therapy (RRT)
TASK 3: Acute Liver Failure & Jaundice
Duration: 2 hours
Complete the two RCEM Learning Modules on Acute Liver failure and Jaundice.
You should familiarise yourself with relevant Local Guidelines, for East Midlands Trainees we are aiming to host these on the website shortly (although this may password protected).
In the meantime please review your local guidelines relevant to chest pain.
We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.
Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.
Part of the face-to-face teaching will be spent discussing the case(s) below:
Here are some extra resources to review if you want more information:
Bromley Case of the Week:
Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form: