RCP Medicine Podcast Episode 101: Acute Liver Failure: Differentials, Deterioration and Decisive Action
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Feb 25, 2026 Mhairi Donnelly, a transplant hepatologist specializing in acute liver failure and transplant care. They discuss urgent differentials for massive transaminases, key early investigations and monitoring, recognizing deterioration and when to escalate care. Practical tips on management decisions, transplant referral triggers, and the role of psychiatric assessment in transplant suitability are highlighted.
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Move Patients To HDU And Monitor Frequently
- Monitor patients with acute liver injury closely with frequent reviews and bloods (six-hourly) and glucose checks every 1–2 hours.
- Manage in a toxicology ward or medical HDU rather than a general ward due to monitoring demands.
Recognise Early Markers Of Deterioration
- Rising lactate despite fluids, worsening creatinine and climbing INR are early poor prognostic markers that often herald progression to acute liver failure.
- Any alteration in mentation requires ICU involvement and early transplant unit discussion.
Use Early RRT As Metabolic Support
- Insert a urinary catheter early and consider renal replacement therapy not just for volume/creatinine but for metabolic support like persistent hyperlactatemia, high ammonia, and temperature control.
- Use RRT thresholds beyond usual indications in acute liver failure.