Abstract
Liver failure can occur in patients with or without underlying chronic liver disease
(mainly cirrhosis) and is, respectively, termed acute on chronic liver failure or
acute liver failure (ALF). In both cases, it is associated with marked systemic inflammation
and profound hemodynamic disturbances, that is, increased cardiac output, peripheral
vasodilation, and decreased systemic vascular resistance, on top of several superimposed
etiologies of shock. In patients with cirrhosis, sepsis is the main cause of intensive
care unit admission but portal hypertension-related gastrointestinal hemorrhage is
also common. Septic shock is also particularly frequent in patients with ALF and can
complicate the initial hypovolemic shock related to poor oral intake, vomiting, and
encephalopathy prior to admission. Given the susceptibility of the liver to hypoxia
and also the potential deleterious effects of fluid on liver function, the assessment
of hemodynamic status and volume responsiveness is especially important in these patients.
However, one should keep in mind that the hyperdynamic state and low systemic vascular
resistance in liver failure may bias the accuracy of some hemodynamic monitoring devices.
Fluid therapy should use crystalloids, and balanced salt solutions may limit the risk
of hyperchloremic acidosis and subsequent adverse kidney events. Nevertheless, the
beneficial effects of albumin resuscitation have been demonstrated in patients with
cirrhosis and may reflect more than mere volume expansion.
Keywords
acute on chronic liver failure - acute liver failure - circulatory dysfunction - hemodynamic
management - fluid therapy
