Acute Liver Failure in a 64-Year-Old Man

Gregory Taylor, DO; Adam M. Vieder, DO

Disclosures

March 29, 2019

Physical Examination and Workup

Upon arrival at the intensive care unit, the patient was afebrile. His blood pressure was 94/57 mm Hg (on norepinephrine at 20 µg/h). His heart rate was 92 beats/min. His respiratory rate was 22 breaths/min. His weight was 196 lb (87 kg). His oxygen saturation was 96% on the ventilator.

Upon physical examination, he exhibited diffuse jaundice, smelled of alcohol and tobacco, and appeared much older than his stated age. He was in no acute distress. He had bilateral scleral icterus. His cardiopulmonary examination findings were unremarkable for any acute changes. His abdominal examination revealed a fluid wave with the absence of any peritoneal signs.

Pertinent laboratory evaluation findings included the following:

  • Hemoglobin level: 10.5 g/dL

  • Thrombocytopenia (110 bil/L)

  • Sodium level: 146 mmol/L

  • Potassium level: 4.6 mmol/L

  • Carbon dioxide level: 21 mmol/L

  • Blood urea nitrogen level: 26 mg/dL

  • Creatinine level: 3.02 mg/dL

  • AST level: 2094 U/L

  • ALT level: 1685 U/L

  • Total bilirubin level: 0.4 mg/dL

  • International normalized ratio: 2.11

  • Troponin level: 35.25 ng/mL (increasing to 44.66 ng/mL)

  • Acetaminophen level: 237 µg/mL

  • CPK level: 57,000 IU/L

Ultrasonography of the abdomen revealed an increased hepatic echogenicity suggesting diffuse hepatocellular disease, cirrhosis, and small amount of perihepatic ascites.

Cardiology assessment found that the elevated troponin level was multifactorial, with a type 2 myocardial oxygen supply and/or demand mismatch secondary to coronary endothelial dysfunction, hypotension, volume depletion, rhabdomyolysis, acute renal failure, and hepatic failure. Non–ST-segment elevation myocardial infarction was most likely the result of plaque rupture in the setting of acute renal failure and fulminant hepatic failure.

Given the patient's multisystem organ failure and poor prognosis, conservative treatment was recommended. He was started on a low-intensity heparin infusion for 48 hours. The transplant surgery team deemed him to be a poor candidate from a surgical perspective for a liver transplant, with concerns regarding compliance, cardiac status, alcohol intoxication, and a suicide attempt.

By day 3, the patient's creatinine level rose to 4.18 mg/dL, and he was anuric. His AST level increased to 3895 U/L, and his ALT level increased to 3215 U/L, despite intravenous NAC administration. His lactic acid level increased from 2.2 to 8.2 mmol/L, with an anion gap of 25. He subsequently underwent dialysis.

By day 4, vancomycin and piperacillin/tazobactam were initiated for healthcare-associated pneumonia. Chest radiography revealed hazy opacities in the lung bases (Figure 1).

Figure 1.

Despite maximal pressor support, the patient continued to decline and remained unresponsive on the ventilator. A family meeting was held, and they elected to withdrawal care. He died shortly thereafter.

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