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Hepatology

Acute Liver Failure (ALF)

A comprehensive case study of 8 patients managed in Kisumu County Referral Hospital and Aga Khan Hospital, Kisumu (2022-2025)

Dr. Otedo Amos – Consultant Physician & Gastroenterologist
2022-2025
Kisumu County Referral Hospital & Aga Khan Hospital

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Definition & Introduction

Acute Liver Failure (ALF) is a rare, life-threatening liver condition with rapid loss of function. It presents with altered mental status and coagulopathy (INR > 1.5) in patients without prior liver disease. Often affects young adults, with high morbidity and mortality.

Key Characteristics:

  • Rare, life-threatening liver condition
  • Rapid loss of liver function
  • Altered mental status (hepatic encephalopathy)
  • Coagulopathy with INR > 1.5
  • Occurs in patients without prior liver disease
  • Often affects young adults
  • High morbidity and mortality

Case Series (2022–2025)

Patient Demographics

Total Patients:8 patients
Female:3 patients
Male:5 patients

Treatment Locations

  • Kisumu County Referral Hospital
  • Aga Khan Hospital, Kisumu

Causes Observed:

HIV
Anti-TB Drugs
Herbs
Sepsis
Unknown

Diagnosis

Clinical

  • • Jaundice
  • • RUQ pain
  • • Ascites
  • • Encephalopathy

Laboratory

  • • LFTs
  • • INR
  • • CBC
  • • Ammonia
  • • Lactate

Imaging & Tests

  • • Ultrasound (ascites common)
  • • Viral hepatitis panels
  • • Toxin screens

Pathophysiology

Rapid hepatocyte failure leads to toxin buildup, resulting in cerebral edema and multi-organ dysfunction.

Pathophysiological Cascade:

  1. Rapid hepatocyte failure → Loss of liver function
  2. Toxin buildup → Accumulation of harmful substances
  3. Cerebral edema → Brain swelling
  4. Multi-organ dysfunction → Systemic complications

Role of Neutrophil Extracellular Traps (NETs):

NETs are implicated in inflammation, cytotoxicity, and thrombosis formation in ALF.

Etiology

Viral Hepatitis

  • • Hepatitis A, B, E
  • • Especially E in pregnancy

Drugs

  • • Acetaminophen
  • • NSAIDs
  • • Antibiotics
  • • Anti-TB drugs
  • • Herbs

Toxins

  • • Mushrooms
  • • Carbon tetrachloride

Other Causes

  • • Pregnancy-related syndromes (HELLP, acute fatty liver, eclampsia)
  • • Autoimmune hepatitis
  • • Vascular disorders
  • • Malignancy
  • • Sepsis
  • • Unknown causes

Clinical Presentation

Early Symptoms

  • • Fatigue
  • • Nausea
  • • Abdominal pain
  • • Subtle mental changes

Progressive Symptoms

  • • Jaundice
  • • Hepatic encephalopathy
  • • Coagulopathy
  • • Multi-organ dysfunction

Hepatic Encephalopathy Grading

GradeClinical Features
Grade 1Mild confusion, altered mood
Grade 2Lethargy, inappropriate behavior
Grade 3Marked confusion, stupor
Grade 4Coma

Treatment

ICU Care

Organ support and close monitoring

Supportive Therapy

  • • Fluids
  • • Vitamin K
  • • Rifaximin
  • • Lactulose
  • • Oxygen
  • • Mannitol

Advanced Therapies

  • • Cause-specific therapy
  • • Liver transplant (best treatment)

Complications

Major Complications:

  • Hepatic encephalopathy
  • Cerebral edema
  • Renal failure
  • Infections
  • Coagulopathy
  • Metabolic imbalances

Challenges in Kenya

High ICU Costs

30k–250k KES/day in private

Resource Shortages

  • • Shortage of ICU beds
  • • Specialized staff shortage
  • • Diagnostic resources limited

System Issues

  • • Delays in referral worsen outcomes

Prognosis

Kisumu Study Outcomes

5
Survived
3
Died
62.5%
Survival Rate

Prognosis Depends On:

  • • Cause of ALF
  • • Timing of treatment

Better Outcomes With:

  • • Advanced liver support
  • • Transplantation

Conclusion

ALF can be managed with strong infrastructure and early diagnosis.

Key Requirements:

  • Improving health systems and referral networks is crucial