Early referral to a liver transplantation center is essential since: a) it is difficult to predict which patients will recover spontaneously; b) deterioration can occur very suddenly; c) there is a shortage of donor organs and the chance of receiving a transplant is greater with early placement on the waiting list; and d) once brainstem herniation has occurred, patients are not salvageable by liver transplant or by any other means.

It is important to recognize etiologies of fulminant hepatic failure in which transplantation is contraindicated. These include diffuse infiltration of the liver by lymphoma or extensive liver metastases as an initial manifestation of malignancy. Hepatic ischemia can be a manifestation of left-sided ventricular failure without signs of congestive heart failure. Acute hepatic vein thrombosis, with fulminant failure as a result of venous outflow block, is best treated with a decompression procedure (side-to-side portacaval shunt) rather than organ replacement.

Options for Hepatic Support

Due to the severe shortage of human donors, many patients with acute liver failure die waiting for a suitable organ. For this reason, these patients should be referred to centers which are not only capable of liver transplantation, but which are also capable of supporting such patients until an organ becomes available. In addition to standard medical supportive measures, several strategies are being developed to provide temporary hepatic support.(Table 9.4) These options are discussed in the ensuing section.

Charcoal hemoperfusion systems have been evaluated as artificial liver support devices. Although some studies have suggested a survival advantage with fulminant hepatic failure of certain etiologies7, most patients do not appear to benefit. Other forms of artificial liver support have included dialysis-like systems coupled with absorbant technology. One system in this category, which is currently under-

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