Chronic Liver Failure

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Introduction   

Chronic liver failure is present in about two percent of the United States population based on a 2017 report from the Centers for Disease Control and Prevention: National Vital Statistics. This totals about 4.5 million adult Americans.23 In 2017, there were 1.32 million deaths (two – four percent) globally which were directly caused by cirrhosis.20;22 With such staggering statistics, it is important to understand the normal function of the liver, what chronic liver failure is and how it develops, how it can be prevented, and how it can be treated. 

Definition 

Unlike acute liver failure, chronic liver failure occurs progressively over a lengthy period of time. It is largely attributed to inflammation and degeneration of the hepatocytes and by definition has been occurring for at least six months.23 However, typically by the time chronic liver failure is diagnosed, the damage has been occurring for years.5 

Liver failure occurs in a somewhat linear fashion. An initial insult occurs leading to inflammation, liver cells become damaged, and the liver tissue regenerates. With continuous inflammation, destruction, and regeneration, the new liver tissue develops fibrosis (scarring and stiffening). Eventually, the constant regeneration leads to cirrhosis (irreversible stiffness). In the end, the healthy liver tissue is reduced to such an extent that the liver’s function is severely compromised.5;23 

While there are many factors that can influence liver functioning, the biggest contributors are cirrhosis (alcohol-related or not related to alcohol), hepatitis (autoimmune or viral), and non-alcoholic fatty liver disease (NAFLD) which has been linked to obesity, metabolic syndrome, and type two diabetes.16 Regardless of the triggering factor, the process of degeneration and regeneration are similar. 

Importance 

General Information 

The liver is required for all life functions. One of the better known functions is its ability to detoxify dangerous metabolic products created by medication, food, or other toxic compounds. This occurs by the conversion of fat-loving molecules into water-soluble compounds which can be more easily removed through urination.8;11 It also plays a key role in the synthesis of proteins, including albumin, and clotting factors in the coagulation cascade. Various substances are produced (fat and bile) while others are stored for future use (vitamins, minerals, and glycogen).2;11;23 

Since it plays so many roles critical to sustaining life, it is important to understand why chronic liver failure now affects nearly two percent of adult Americans. As previously mentioned, there are several modifiable lifestyle factors which can contribute to the development of liver damage and subsequent failure. The two biggest contributing factors are alcohol use and obesity. Metabolic syndrome has also been linked to the development of fibrosis and cirrhosis but one of the defining features of metabolic syndrome is obesity. Both alcohol consumption and obesity can be addressed on a personal level.16 

While the vast majority of patients diagnosed with chronic liver failure are of caucasian ancestry, this condition also occurs in ethnically marginalized groups; however, it may be underdiagnosed. While chronic liver disease is driven mainly by the hepatitis C virus in African Americans and alcohol use in white Americans, non-alcoholic fatty liver disease is the largest risk factor in other ethnic groups.15;21 

Financial Impact 

The care for people with liver failure can be quite intensive and expensive for the healthcare system. Evaluation and diagnosis includes laboratory testing and radiographic exams such as computed tomography (CT) or magnetic resonance imaging (MRI). There are also more finely-tuned imaging tests to specifically look at the elasticity of the liver and assess for fibrosis and cirrhosis. Biopsies can be done to determine the makeup of liver tissue.  

Treatments range from those geared to mitigate symptoms (such as esophageal varices, hepatic encephalopathy, hepatorenal syndrome, or hepatocellular carcinoma (HCC)), address root causes (viral infections, autoimmune conditions, alcohol or other substance use, or genetic conditions), or cure the condition entirely (via transplant). 

Regardless of the required treatment, the burden on the healthcare system has actually outpaced that seen for those with congestive heart failure. This is felt on both an individual and collective level. Patients, and their families, may quickly exhaust their personal insurance or other financial resources if they require hospitalization or intensive treatment or monitoring. Collectively, medical assistance resources can also be heavily utilized. Both make the cost of healthcare increasingly expensive. Financial strain inevitably also leads to mental strain, a decreased quality of life, and can further worsen an individual’s overall health status.25 

Quality of Life Considerations (Brief) 

In general, chronic health conditions adversely affect one’s quality of life. In the case of chronic liver failure, the individual typically does not feel well, has difficulty completing everyday tasks, and suffers mental distress related to both their disease and the treatments. Caregiver strain is also prevalent in this group.9;25 

Anatomy and Physiology of the Liver 

The liver plays many roles. It is the master processing organ and takes digested nutrients from food (via the portal vein) and converts them to required substances for normal bodily functioning. These can either be immediately used or stored for later use (such as the case with glycogen). Toxins are also pulled from the bloodstream and converted into a more excretable form. Excretion occurs via the kidneys or the bowels.11 

Detoxification 

Detoxification is a critical function of the liver because the body receives numerous toxic insults every day. Whether these insults are in the form of medications, pesticides, or toxins in the water, the liver is the key organ to remove these from the bloodstream before lasting damage occurs. These toxins are converted to a more stable form and sent to the kidneys for excretion. A key example of this is the conversion of ammonia to urea which is filtered into the urine.11 

Protein Synthesis and Metabolism 

There are also a plethora of proteins made in the liver. These include albumin (critical for the regulation of blood pressure and volume and the transport of nutrients) and clotting factors. These clotting factors are required for normal coagulation. 

The liver also breaks down proteins into amino acids for reuse and destroys degraded red blood cells.11 

Bile Production and Fat Metabolism 

Bile is produced in the liver and stored in the gallbladder. This important liquid is required for the breakdown and absorption of fats in the small intestine. The liver produces about 800 to 1,000 milliliters of bile per day. 

Fat breakdown is required to generate energy at the cellular level. Fat absorption may be temporarily affected if the gallbladder has been removed.11 

Storage of Vitamins, Minerals, and Glycogen 

The liver is responsible for the packaging and storage of many essential molecules. Notably, the liver plays a key role in blood sugar management. Glucose is stored as glycogen when there is an abundance in the bloodstream. Conversely, if the blood glucose levels are low, glycogen can be metabolized and glucose released into the circulation. 

Key vitamins and minerals are also stored in the liver. These include copper and iron which are essential for life functions such as the production of hemoglobin and red blood cells.11 

Consequences of Liver Dysfunction 

As detailed above, the liver plays many roles in sustaining life. This occurs via the breakdown and excretion of toxins, key protein production, and the absorption and storage of nutrients.  

In cases where detoxification cannot happen properly or effectively, toxins cannot be appropriately processed or removed. This can lead to the buildup of dangerous chemicals in the body which can cause inflammation or damage to bodily tissues. Ammonia buildup, if not properly converted to urea, can contribute to conditions such as hepatic encephalopathy causing mental confusion, disorientation, coma, and even death.3;23 

Protein production, especially of clotting factors and albumin, is another key function of the liver. If these proteins cannot be properly assembled from the required amino acids, many complications can result. These may include increased bruising, decreased intravascular volume, third spacing and/ or edema, or hemorrhaging (especially in the esophagus or stomach).5 

Finally, the absorption of nutrients (especially fat) will be altered. The storage of various compounds such as vitamins, minerals, and glycogen will also be impeded. Fat digestion and absorption is directly related to the production of bile. Less bile equals less fat digestion. Fat can accumulate in the liver further perpetuating the damage which initially led to chronic liver failure. If insufficient quantities of iron or copper are stored, hemoglobin and red blood cell production will be adversely affected. If glycogen cannot be generated, stored, and released when the serum blood glucose levels require it, blood glucose management is less than optimal.11 

Causes of Chronic Liver Failure 

Alcoholic Liver Disease 

One of the four main causes of liver failure leading to hospitalization, chronic alcohol use causes repeated liver stress, inflammation, and cirrhosis.5;10;27  

In alcoholic-liver disease, the normal metabolism of alcohol is thwarted. Normally, alcohol is converted to acetaldehyde and then to acetate (by alcohol dehydrogenase and acetaldehyde dehydrogenase, respectively). When this process is shifted to favor the production of a specific chemical compound, fatty acids and triglycerides cannot be metabolized and build up in the liver. This process draws the immune system to the hepatocytes and damage ensues.19 

Alcoholic liver disease occurs in four phases beginning with steatosis in which fatty droplets begin to build up in the liver. Slowly, the fat droplets become so numerous that they replace and repeatedly inflame the liver tissue resulting in hepatitis. Finally, with continued progression of hepatitis and alcohol use, the liver becomes permanently scarred (cirrhosis), begins to fail, and is likely to display portal hypertension. Additional factors that contribute to the development of alcoholic liver disease are female gender (as assigned at birth), obesity, and a high fat diet.19 

Chronic Viral Hepatitis 

Hepatitis B and C are the second and third of the four main causes leading to hospitalization for individuals with chronic liver failure. These viruses lead to chronic hepatitis. In turn, fibrosis and cirrhosis develop leading to liver failure. However, a steep reduction in morbidity and mortality of viral-associated hepatitis and liver failure has been seen with the advent of antivirals for hepatitis B and C.10;27 

It is estimated that there are 257 million people worldwide living with chronic hepatitis B while 71 million live with chronic hepatitis C.22 Antiviral and immunosuppressive medications have been shown to ameliorate damage through viral suppression and in the case of hepatitis C have been shown to eliminate the virus.23;26 Hepatitis B vaccination can prevent infection by the hepatitis B virus and eliminate the risk of subsequent damage.20;26 

Non-Alcoholic Fatty Liver Disease 

Non-Alcoholic Fatty Liver Disease (NAFLD) is the fourth leading cause of hospitalization in chronic liver failure.10 The biggest risk factors for non-alcoholic fatty liver disease include obesity, metabolic syndrome, and type two diabetes.16 Recently, NAFLD was renamed metabolic dysfunction-associated steatotic liver disease (MASLD). It is estimated about 30% of the population has NAFLD/ MASLD. Likewise, nonalcoholic steatohepatitis (NASH) has been renamed metabolic dysfunction-associated steatohepatitis (MASH). In addition to obesity and type 2 diabetes, dyslipidemia and insulin resistance can also contribute to the development of NAFLD/ MASLD.5;6 

NAFLD/MASLD is further broken down into nonalcoholic fatty liver (NAF) and NASH/ MASH. Similar to alcoholic liver failure, but without the previous alcohol exposure history, fat globlets build up in the liver causing inflammation, fibrosis, and permanent scarring (cirrhosis).16 A long-term follow-up study evaluating the prognosis of NAFLD, and the frequency with which it is accompanied by obesity and diabetes, did not suggest that assumptions could be made based strictly on body mass.22 

HCC is directly linked to NAFLD/ MASLD. The most effective treatments for NAFLD/ MASLD consist of bringing one’s weight into a healthy range, normalizing metabolic markers such as blood glucose and cholesterol, and maintaining a healthy blood pressure.6;16 

Autoimmune Hepatitis 

Autoimmune hepatitis is caused when the immune system produces antibodies targeted at normal liver parenchyma. This chronic damage causes inflammation, fibrosis, and liver failure. Typically, this condition is not diagnosed until cirrhosis has already occurred. Women are more predisposed to autoimmune hepatitis than men.23 

There are at least three disorders which are mediated by the immune system. These include autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC). 

AIH is defined by the presence of anti-smooth muscle antibodies, antinuclear antibodies, and/ or high levels of gamma globulin.23 

PBC is diagnosed based on progressive inflammation and scarring in the portal veins and destruction of the biliary channels in the liver. This disease is diagnosed predominantly in middle-aged women and causes jaundice and fibrosis in addition to elevated alkaline phosphatase levels.23 

Finally, PSC is diagnosed with a decreased lumen size in the intrahepatic and extrahepatic bile ducts. This is directly related to chronic scarring and subsequent fibrosis. Usually, this condition is seen in the setting of ulcerative colitis.23 

Genetic and Metabolic Disorders 

In addition to metabolic, infectious, and immune causes, there are genetic causes of chronic liver damage and failure as well. These genetic disorders lead to metabolic conditions causing the accumulation of certain minerals or a protein deficiency leading to liver (and lung) damage.4 

Hereditary hemochromatosis and Wilson’s disease are both caused by genetic changes following an autosomal recessive pattern. In both cases, the individual inherited two faulty copies of a gene (one from each parent).23 

Due to a mutation in the HFE gene, hereditary hemochromatosis shows up in middle adulthood in most cases (typically, after age 40 in males and age 60 in females and/ or after menopause). In this case, the body absorbs more iron from the gastrointestinal tract than normal leading to an accumulation of total iron in the forms of ferritin or hemosiderin. This iron is stored in the liver, pancreas, and heart and can lead to the generation of free radicals causing tissue damage in the form of fibrosis. Regular apheresis can maintain more normalized iron ratios and slow the rate of organ damage.13;23 

In the case of Wilson’s disease, mutations in the ATP7B gene lead to defects in the protein called copper ATPase 2. This directly affects the transport of copper and leads to a buildup of copper in the cells– especially of the liver, eyes, and brain. Symptoms typically appear during adolescence and manifest as liver, neurological, and psychiatric impairment.17 

A deficiency of alpha-1 antitrypsin occurs when the SERPINA1 gene is mutated. This mutation leads to a lower than expected level of alpha-1 antitrypsin in the lungs and a buildup of alpha-1 antitrypsin in the liver. A single mutated copy of the gene affects about one in 25 people of European heritage but it is rarely seen in other non-European populations. About one in 3,500 people have two defective copies. Alpha-1 antitrypsin is made in the liver and shipped to the lungs to function as the “off switch” for an enzyme called neutrophil elastase. This modulation of neutrophil elastase prevents lung damage. However, if alpha-1 antitrypsin cannot get to the lungs (due to a low amount or a defective structure) then lung tissue can become damaged and alpha-1 antitrypsin builds up in the liver. This buildup causes fibrosis and cirrhosis. Without a liver transplant, this condition is incurable.4 

Drug-Induced Liver Injury 

All substances are processed through the liver. This includes medications (both prescription and over the counter) and herbal supplements. Several medications are known to have a higher incidence of liver damage and should be taken with special care. These include acetaminophen, amiodarone, isoniazid, methotrexate, phenytoin, and nitrofurantoin. Herbal substances like green tea extract can also cause damage. Liver damage associated with medicinal substances can be dependent on the dosage, duration of administration, or both.7;23 

Several factors make it more likely that particular individuals may develop liver toxicities from these medications. These factors include: older age, being assigned female at birth, and a higher body mass index. Usually, once the problematic product is stopped, the liver can begin its recovery. About 90 percent of patients recover while ten percent will need a liver transplant. In some cases, prolonged damage to the bile ducts can lead to “vanishing duct syndrome”.7;23 

Pathophysiology of Chronic Liver Failure 

Cirrhosis and Liver Fibrosis 

The trajectory of liver failure begins with the initial injury. This can occur for any of the reasons listed above, in addition to other causes. The inciting injury causes damage to the liver parenchyma leading to inflammation, the development of scar tissue, and the regeneration of new nodular tissue by hepatocytes, hepatic stellate cells, and fibroblasts. Chronic damage and inflammation lead to continued scarring and eventually the liver becomes stiff as scarred tissue distorts the liver’s normal cellular makeup. Over time, as the liver becomes stiff and cirrhotic the blood flow is decreased leading to cell death.23 

The speed at which this progress occurs is contingent on the specific impetus and the level of exposure. In one study, viral infections (such as a coinfection with HIV and hepatitis C) seemed to produce the fastest irreversible damage while biliary cirrhosis produced the slowest.23 There is also some evidence that gene manipulation may be a tool which can be used to restore liver function leading to improved regeneration, function, and overall survival.2 

Compensated Vs. Decompensated Cirrhosis      

Once the liver has become cirrhotic, there are two ways to describe its level of function. The terms compensated and decompensated are used to delineate cases of adequate functioning from inadequate functioning and liver failure.  

• Compensated: This type of liver failure may be nearly asymptomatic even though there is severe cirrhosis and damage present on exam. The individual with compensated liver failure may not feel ill and may present with symptoms of fatigue and weakness, anorexia, nausea, vomiting, weight loss, and/ or fever. The hallmark symptom is right upper abdominal pain. Blood flow and functioning are not normal but they are also not severely impaired. However, as the disease progresses, more symptoms develop as the liver shrinks and loses critical access to the normal blood supply.1 

• Decompensated: In decompensated liver failure, the liver is severely damaged and the individual looks and feels sick. Likely, they will begin to exhibit jaundice, symptoms of hepatic encephalopathy, portal hypertension, and hepatorenal syndrome. As the liver shrinks and the hepatic blood supply is compromised because of cirrhosis, the liver functions even less effectively. Portal hypertension and hepatic encephalopathy will be discussed in more detail below.1 

Hepatorenal syndrome indicates that the kidney’s function is now compromised. While the kidney anatomy is completely normal, the steep decrease in liver function due to damage causes a slow loss of renal function. The liver normally releases certain vasoconstrictors, including angiotensin. However, in cases of liver damage, this increases and causes the renal vasculature to narrow thereby reducing kidney function. Several criteria can define hepatorenal syndrome including:23 

• Portal hypertension or liver failure in the setting of liver disease 
• Consistently increasing creatinine (potentially doubling within the span of several days) 
• Decreased urine output (no or little protein) 
• Low urine sodium 
• No evidence of shock 
• No recent drugs leading to kidney toxicity 
• No renal disease 
• No improvement when using volume expanding medications and ceasing diuretic use  

Portal Hypertension 

Portal hypertension is another phenomenon seen in cases of advanced liver disease and decompensated liver failure. Damage to the liver parenchyma and severe scarring impinge on the blood flow through the hepatic artery and hepatic portal vein. This causes an increasingly reduced ability for the liver to filter out toxins and other substances from the blood. Due to the reduced ability to enter the liver, this blood supply develops a collateral circulation. 

Portal hypertension is officially diagnosed when testing reveals a portal venous pressure higher than 7 mmHg. However, until pressures reach 12 mmHg or higher, symptoms will not typically be evident. Several well-known complications can develop from portal hypertension. These include:23 

• Esophageal or gastric varices: Blood flowing in collateral pathways through the esophagus and stomach creates outpouchings in the vasculature wall due to unexpected blood volume. This can lead to bleeding. Variceal-related bleeding is the most common serious complication seen in chronic liver disease and failure.1;23 

• Ascites and caput medusae: When fluid cannot be funneled to the kidneys due to increased portal vein pressure and decreased serum albumin, it can accumulate in the abdominal cavity. The caput medusae is the formation of swollen veins around the umbilicus because of this distension. Eventually, severe ascites can result in dyspnea and anorexia due to early satiety.1;23 

• Rectal hemorrhoids: Rectal hemorrhoids develop for similar reasons to esophageal and gastric varices. Portal hypertension causes a diversion of the blood flow to alternative pathways including the veins around the rectum.23 

Hepatic Encephalopathy 

Hepatic encephalopathy can develop when toxins (not detoxified by the liver) build up in the body. The main toxin of concern is ammonia. Hyperammonemia can cause impaired neurological functioning and level of consciousness. Ammonia levels above 30 micromol/ liter are diagnostic for hyperammonemia in adults.3;23 

Hepatic encephalopathy is graded on a zero to four scale.23 

• Grade 0- minimal symptoms- normal mentation; possible minor impairment in memory, coordination, and other intellectual functioning 

• Grade 1- mood changes (anxiety or euphoria), decreased ability to focus and maintain attention, changes in sleeping patterns, impairment in basic math skills 

• Grade 2- more noticeable changes in personality, unusual and inappropriate behaviors, loss of orientation to time, decreased coordination and loss of motor skills, tremoring, malaise, and feelings of apathy 

• Grade 3- difficulty remaining awake, decreased responsiveness to stimulation, almost complete disorientation, confusion, and abnormal behavior 

• Grade 4- most severe- coma- possibly leading to death 

An individual can exhibit any of these symptoms although altered sensation is usually the presenting symptom. Changes in electrolytes (especially potassium), co-infection, bleeding varices, shunting via a transjugular intrahepatic portosystemic shunt (TIPS) procedure, and certain medications can worsen hepatic encephalopathy symptoms.23 

Hepatic encephalopathy is treated by reducing the ammonia level in the blood. This can be done with medication (such as lactulose) or dialysis.3 

Signs and Symptoms of Liver Failure 

Early Signs (Compensated Liver Failure) 

As mentioned previously, an individual with compensated liver failure may have very few, if any, symptoms. The symptoms are also vague and non-specific, so a thorough history and diagnostic workup will be required to diagnose compensated liver failure. Symptoms that may be present include:1;23 

• Increased tiredness 
• Malaise 
• Nausea 
• Vomiting 
• Right upper quadrant discomfort (mild) 
• Mild elevation in liver enzyme on testing 

Advanced Symptoms (Decompensated Liver Failure) 

As mentioned above, the signs of decompensated liver failure are much more severe and the individual will feel and look ill. Not only will they have fatigue and lethargy, but nausea and vomiting are more likely, and abdominal pain is more severe. Symptoms of advanced disease may include:1;23 

• Weight loss (related to anorexia) 
• Muscle wasting 
• Ascites and caput medusae 
• Esophageal and/ or gastric varices (potentially bleeding) 
• Rectal hemorrhoids 
• Vomiting (likely positive for blood) 
• Bloody stools 
• Hepatic encephalopathy (likely manifested as confusion but may be accompanied by many other symptoms depending on the severity) 
• Decreased blood clotting/ easier bruising and bleeding (due to decreased production of clotting factors made in the liver) 
• Jaundice of the eyes and skin 

In addition to the signs and symptoms of decompensated liver failure, HCC is much more likely to occur in those with chronic liver failure.1;23 

Quality of Life Deeper Dive 

Liver failure has a significant effect on the quality of life, especially in the later stages. This decrease in quality of life may be due to the disease itself (symptoms, effect on daily activities, and/ or recommended treatments), mental toll, the need for intensive and frequent medical care, feelings of isolation, and social stigma. A retrospective literature review found that two key facets missing in the typical care of patients with liver failure hinge on helping the individual understand their disease and how they can optimize their quality of life.9 

In the case of a life-altering chronic disease, it is also not only the individual with chronic liver failure who is affected but their family, friends, and coworkers as well. Frequently, the patient will not vocalize concerns regarding their mental health or worries or any difficulties they have maintaining their previous level of social engagement or employment. These topics are felt to be private but if the healthcare team is unaware of these concerns, then the patient and their family will suffer in silence.9 

This retrospective review identified that patients and their families need to be provided with written information regarding their current disease status and the expected progression so they can prepare for the future. However, this material needs to be written at the appropriate level for the expected level of health literacy in the general population.9 

There was also a common theme that increased support from the healthcare team in managing their liver disease would be helpful and appreciated. A thorough needs assessment must be performed for the individual patient and assumptions must be avoided. Additional support from the healthcare team could be provided or the individual and their family could be referred to support organizations specializing in living with chronic liver disease. Finally, the healthcare team must not stigmatize the individual with liver failure (typically, related to etiology) because that will lead to a patient who feels less supported and less likely to seek healthcare.8 

Diagnosis of Chronic Liver Failure 

Clinical Evaluation 

A thorough history and physical is of paramount importance when an individual is being evaluated for chronic liver failure. Obtaining a full history, including alcohol use and the regular use of hepatotoxic drugs, can provide the first indicators of the etiology behind suspected liver failure. Of course, viral hepatitis testing can determine if hepatitis B or C is the causative agent. Finally, metabolic disease must be evaluated. Not only does this include genetic diseases causing iron or copper overload or alpha-1 antitrypsin deficiency but diabetes, obesity, and metabolic syndrome must also be assessed. 

Laboratory Tests 

Many blood tests can provide insight into liver failure. These include direct testing of liver function, coagulation testing, and determining ammonia levels.  

In chronic liver damage and failure, the hepatocytes release both aspartate aminotransferase and alanine aminotransferase in higher concentrations– possibly two or three times higher than normal. Alkaline phosphatase is more indicative of biliary conditions such as PBC. Increased bilirubin is also noted in chronic liver failure (especially when jaundice is present). It is important to note that these tests may not be much outside of the normal range, if at all, in compensated liver failure.23 

Clotting factors are made in the liver. When its function is compromised, so is the production of these important molecules. In liver failure, prothrombin time (PT)/ international normalized ratio (INR) and activated partial thromboplastin time (APTT) times are increased, signifying a lower than normal concentration of clotting factors. Platelet counts are typically low because of portal hypertension and the resulting increase in spleen size.23 

Finally, as mentioned previously, higher than normal ammonia levels are the main causative agent in hepatic encephalopathy. In the setting of increased ammonia levels and hepatic encephalopathy, serum albumin levels will also be abnormally low.23 

Imaging Studies 

Several imaging modalities are useful in the context of chronic liver failure. These include ultrasound, CT, and MRI. Some lesser used imaging tests include doppler scans, elastography, and wedge hepatic venous pressure. 

Ultrasound is diagnostic for cirrhosis and can visualize the liver size and anatomy, including nodules, determine if clots are present, and determine the diameter of the portal vein. Abdominal fluid can also be visualized to determine if ascites is present. Ultrasounds can identify tumors, including HCC.23 

CT and MRI provide a clearer visualization of any liver lesions or obstructions in the biliary ducts. A specialized triphasic CT is the best test for evaluating HCC.23 

Doppler scans are ideal for evaluating blood flow and assessing for clots, venous malformations, or obstructions.23 

Wedge hepatic venous pressure can assess the portal venous pressure and determine if portal hypertension is present.23 

Elastography is useful in detecting cirrhosis in its earliest stages and relies on evaluating the stiffness of the liver. Stiffer liver tissue causes a faster wave pattern on testing and indicates a diagnosis of cirrhosis. Specifically, in NAFLD/ MASLD, heart damage can also be detected. This test can be done via ultrasound.23 

Liver Biopsy 

Liver biopsies are crucial to assess the extent of liver fibrosis and determine if there is any underlying malignancy. This can be done via several different routes including laparoscopic, percutaneous, or transjugular and may be performed as a needle or wedge biopsy.23 

Endoscopy 

The sole reason for performing an endoscopy is to assess the presence and severity of esophageal and gastric varices. This is relevant in cases of portal hypertension. Varices can also be treated endoscopically.23 

Medical Management of Chronic Liver Failure  

Several strategies fall under medical management. These include treating the underlying cause, ameliorating symptoms of chronic liver failure, and managing complications. 

Treating the Underlying Cause 

Treating the underlying cause of chronic liver failure cannot necessarily reverse the damage but may slow disease progression. There are three pillars of treatment for the most common underlying causes. These include:23 

• Reducing or eliminating the viral load in hepatitis B or C through antiviral medication 
• Modifying lifestyle factors including body weight, blood glucose, blood cholesterol, and blood pressure 
• Eliminating the use of alcohol and minimizing or eliminating the use of hepatotoxic medications or supplements; detoxification from previous exposure is also important 

Immunosuppressants and chelation agents are useful for autoimmune-mediated liver failure and iron or copper overload. Ursodeoxycholic acid is required for treating PBC while a transplant is the only treatment for PSC and alpha-1 antitrypsin deficiency.23 

Medications for Symptoms 

Treatment geared to minimize or resolve symptoms focuses on ascites, hepatic encephalopathy, varices, hepatorenal syndrome, and potentially HCC.  

In cases of ascites, the goal is to reduce the fluid burden and edema. This can be accomplished with diuretics, salt and fluid restrictions, paracentesis (in severe or drug-refractory cases), or a TIPS procedure.12 

Hepatic encephalopathy is treated by treating the underlying hyperammonemia. This is done by administering lactulose. Lactulose’s mechanism of action is to change ammonia into ammonium ions. This is less easily absorbed from the gastrointestinal tract. Since constipation is likely in the setting of chronic liver failure, lactulose also exerts an osmotic effect and treats constipation thus further facilitating the excretion of ammonia. In addition to lactulose, rifaximin can help decrease ammonia levels produced by the bacteria present in the colon.23 

When varices are present, there is a greater risk for bleeding events and this is the most common life-threatening complication in chronic liver disease. In this case, vasopressors and fluid administration can be used to treat acute bleeding events. Endoscopy procedures, including banding and sclerotherapy, can treat the bleeding varices directly. Beta-blockers can be used to prevent the progression of esophageal and gastric varices.23 

Hepatorenal syndrome, another serious complication, is treated based on severity and the patient’s treatment location. The overall goal is to reverse the kidney injury by correcting the underlying cause. Treatments can include vasopressors (such as norepinephrine) or albumin combinations (with terlipressin or octreotide). This can help reverse the fluid imbalance by increasing renal perfusion and blood flow in the vasculature. Liver transplant is a curative treatment option.23 

Finally, HCC is treated based on the stage. In the lower-stage setting, resection or ablation of the lesion should cure this malignancy. However, in cases of intermediate staging the treatment of choice is embolization of the lesions via chemotherapy or radiation. In the metastatic setting, sorafenib is the approved agent.23 

Management of Complications 

As mentioned above, the biggest complication in chronic liver failure is the presence of bleeding varices. This is treated by endoscopic banding or sclerotherapy. Blood transfusions may also be used in cases of heavy blood loss in addition to fluid resuscitation and vasopressor support.14;23 

In cases of spontaneous bacterial peritonitis, which often accompanies ascites, antibiotics are required to clear the infection.23 

Nutritional Support 

Malnutrition related to protein deficiency is often seen in chronic liver disease. In this case, a high-protein diet can be implemented to optimize muscle health and prevent wasting. Based on research, there is a direct correlation with the extent of malnutrition and the severity of liver failure.24 

Many patients with advanced liver disease are malnourished because they no longer eat enough. This can be due to anorexia, nausea, vomiting, or a combination of the three. Nutrient deficiencies, caused by restrictive diets, paracentesis, or certain medications such as lactulose, can also exacerbate malnutrition. It has been shown that outcomes can be improved with an earlier correction of both nutrient deficiencies and malnutrition.24 

To optimize nutrition in cases of chronic liver failure:24 

• Meals should be given more frequently and in smaller portions (ideally, five to seven per day) 
• Food should be well-cooked 
• Late evening snacks may be especially helpful in reducing muscle wasting 
• Higher calorie (and carbohydrate) content foods are preferred; however, the quality of the higher calorie food should be evaluated 
• Supplements including the amino acids leucine, iso-leucine, or valine may be beneficial 
• Protein consumption should target between one and 1.8 grams of protein per kilogram of body weight per day 
• In ascites: sodium and fluid restrictions may be recommended but with great caution 
• Enteral nutrition is a valuable tool in cases where increased oral intake is not possible 

Liver Transplantation 

Liver transplant is curative. However, it is not without its risks and is not indicated in every situation. It is recommended in PSC and alpha-1 antitrypsin deficiency and is curative in both cases. A transplant is also a valid treatment option in cases of refractory hepatorenal syndrome.21 

The Model for End-Stage Liver Disease (or MELD) score is used to determine a patient’s priority for transplant. This calculation uses bilirubin, serum creatinine, and INR to predict mortality after a TIPS procedure and is also useful in estimating overall survival in the case of transplant.19;23 

As with any transplant, there are both risks and benefits.18 

Some of the benefits include: 

• Longer life  
• Better quality of life 
• Less chance of dying from liver failure 
• Increased ability to participate more fully in activities 

The risks may include: 

• Surgical risks such as bleeding and infection 
• Bile duct complications 
• Lifelong immunosuppressant medication 
• Potential for future surgeries related to the transplant 
• Potential transplant failure 

Prognosis 

Factors Influencing Prognosis 

Numerous factors influence the patient’s prognosis. These include both the etiology and the stage of disease at which it is diagnosed. Chronic liver failure caused by viral or autoimmune agents may be difficult to control since viral loads need to be significantly decreased or the immune system needs to be modulated to a more normal level of activity. Cases linked to metabolic symptoms (such as diabetes and obesity) or alcohol use may be a bit easier to manage if the patient is amenable to lifestyle changes and given the appropriate support and resources.23 

Compensated liver disease almost always has a more favorable prognosis since damage is likely not as advanced as in decompensated liver failure. As with all chronic medical conditions, the earlier treatment begins, the better the outcome. In some cases, fibrosis can even be reversed, to an extent, if the correct interventions are implemented such as antivirals, immunosuppressants, methods to control blood sugar, weight loss, and alcohol cessation.23 

The worse prognosis is given when complications are noted in the setting of decompensated liver failure. All complications can be life-threatening and require intervention to prevent worsening and resolve the issue. Child-Pugh and MELD scoring can provide an estimate of a patient’s current status. Both the Child-Pugh and MELD scores factor in predictive clinical characteristics. The Child-Pugh score evaluates for elevated bilirubin and decreased albumin, elevated PT, hepatic encephalopathy, and ascites. The score ranges from five to 15 with a lower number equaling a lower class of liver failure. The MELD score, already described above, is calculated based on bilirubin, INR, and creatinine.23 

Survival Rates and Life Expectancy 

Decompensated liver failure has been shown to have the worst prognosis and the highest correlation with mortality. This is due entirely to complications. The highest mortality rate is seen with bleeding varices. Hepatic encephalopathy is also deadly once it has progressed to its last stages. Survival estimates based on a Child-Pugh score greater than 12 and MELD scores greater than 21 total about six months.23 

A liver transplant can be curative and can extend life to a more commensurate range with what is expected for the specific individual’s age group. They also typically experience a better quality of life and a return to a higher level of function.18;23  

Prevention 

Lifestyle Modifications 

As can be seen, many factors can cause hepatitis, fibrosis, and eventual cirrhosis. There are numerous modifiable risk factors which can be amended to slow and potentially reverse damage. These include:23 

• Limiting alcohol intake 
• Maintaining a healthy weight 
• Controlling blood sugar and cholesterol 
• Avoiding hepatotoxic drugs (acetaminophen, methotrexate, phenytoin, amiodarone, etc.) or supplements 
• Abstaining from iron supplementation unless clinically indicated 
• Taking part in preventative screenings for viral hepatitis 
• Staying up to date on vaccines for hepatitis A and B 

Early Detection and Monitoring 

As mentioned above, individuals need to be screened with preventative care visits to determine if they have any risk factors for chronic liver disease, including routine blood work, or to assess the current stage of known liver failure.  

During routine exams, substance use, exposure history, current medications, and a review of current overall symptoms and body metrics should be reviewed to evaluate for an increased risk. In cases where liver disease is known or suspected, appropriate imaging and diagnostic lab work can be used to determine the extent of disease. If diagnosed with liver failure, regular follow-up and monitoring should ensue.23 

Conclusion

Chronic liver disease is an increasingly common life-altering disease that develops over the course of years and may go undetected for almost as long. Numerous factors can initiate the chronic liver insults that lead to eventual failure and a targeted diagnosis is necessary to define an appropriate treatment plan. Imaging tests, blood testing, and biopsy can determine the etiology and extent of chronic liver damage and failure.  

While liver failure takes a significant toll on both quality of life and the ability to participate normally in everyday activities, there are treatments available to slow, and potentially reverse, the damage done. However, early detection and prevention are even more important to minimize the development of chronic liver failure necessitating intensive treatments and a shortened life span. With adequate education and support, the risks for liver failure can be mitigated and fewer may suffer from this life-altering disease. 

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