Critical Care Considerations in Liver Failure

Igor Barjaktarevic, MD, PhD

Ram Subramanian, MD

Tisha Wang, MD

Liver disease remains a major cause of morbidity and mortality in the United States and worldwide with ∼200,000 hospital admissions annually in the United States alone. Of these admissions, ∼10% of patients will need intensive care unit (ICU) level care. This issue of Seminars in Respiratory and Critical Care Medicine outlines the major critical care issues surrounding hepatic disease in both acute liver failure and acute on chronic liver failure (ACLF), an entity that has been increasingly recognized and defined by acute hepatic decompensation with at least one extrahepatic organ failure in patients with underlying chronic liver disease.

Many of these critical care issues also have important implications in selection and prioritization of patients for liver transplantation. Liver transplant, the definitive cure for both acute and chronic liver diseases, continues to be widely performed with >8,000 transplants annually in the United States with overall favorable long-term outcomes.

The articles in this issue encompass the major acute critical care issues that frequently arise in the patient with liver disease admitted to an ICU. The diagnosis and management of acute liver failure, acute gastrointestinal bleeding, ascites, acute renal failure, electrolyte derangements, acute respiratory failure, hepatic encephalopathy, coagulopathies, infectious complications, and shock in liver disease are discussed in detail. An article on liver replacement therapy provides updates on the current limitations of this therapeutic option as a bridge to liver transplantation or recovery, and a basic science/translational article on the immune dysfunction of liver failure and the similarities to sepsis highlights possible future therapeutic pathways to target in ACLF related to infection. Finally, perioperative management of the liver transplant patient is discussed with a focus on cardiopulmonary management.

We have endeavored to create an issue that is relevant to internists, pulmonologists, intensivists, nephrologists, hematologists, neurologists, anesthesiologists, gastroenterologists, hepatologists, and liver transplant surgeons alike. The myriad of topics in this issue reinforces the real-world need for multidisciplinary teams in the optimal care of patients with liver failure, both before and after liver transplantation. We truly hope that you find this issue valuable and useful in your everyday clinical practice, regardless of your specialty and area of expertise.

We would like to sincerely thank all of our authors for their important and enlightening contributions to this issue of Seminars in Respiratory and Critical Care Medicine. We also owe a debt of gratitude to the editorial board and especially the editor-in-chief, Joseph P. Lynch III, MD, for recognizing the value of this topic and giving us the opportunity to guest edit this important issue of Seminars in Respiratory and Critical Care Medicine.