Management of Acute Liver Failure in Children

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Introduction: Pediatric Acute Liver Failure (PALF) incidence has been increasing in recent times. It is an emergency and needs appropriate management in a specialized center with availability for liver transplant. Methods: In this article, we shall provide an overview of etiologies and approach to the management of PALF. Conclusions: Various known etiologies for pediatric acute liver failure involve infections, immunologic disorders, and metabolic and drug/toxin-mediated illnesses. However, a known etiology for liver failure may be lacking in approximately 30–50% of cases. In developing countries like India, infections still dominate as the leading cause of pediatric ALF, with the hepatitis A virus (HAV) being the most identified etiology. Metabolic disorders account for approximately 23–30 percent of the PALF in infancy or early childhood (less than 5 years). Around 9–52% of children with PALF have indeterminate etiology. Management requires a multidisciplinary approach involving hepatologists, pediatric intensive care specialists, nephrologists, and a liver transplant surgery team. Cerebral edema is the most frightful complication of acute liver failure, which may progress rapidly, leading to irreversible brain damage, so every possible measure should be taken to identify as well as prevent the progression of cerebral edema and raised intracranial pressure. Elective intubation and mechanical ventilation should be started in patients with significant encephalopathy (Grade II). Identification of the need for liver transplantation and early referral for the same before irreversible brain damage sets in. Extracorporeal liver assist devices have shown promising results in bridging these children to native liver survival or liver transplantation, but continuous careful monitoring should be done to assess for treatment failure and the need for liver transplantation. Liver transplantation is the only definite treatment that improves survival in PALF, and with several advances in surgical techniques and good intensive care, the overall survival after LT for ALF has improved significantly.