Acute Liver Failure in Kolkata: Causes & Emergency Care

Key points

Acute liver failure = a new, severe liver injury plus a clotting problem (raised INR) plus any degree of confusion or drowsiness, in someone without prior liver disease.
In India, common causes include hepatitis E and A, anti-tuberculosis drugs, herbal and indigenous medicines, rat-poison ingestion and Wilson disease; paracetamol overdose is also a cause.
Condition can change within hours. Transfer to a transplant centre before the patient is deeply unconscious keeps the transplant option open.
Doctors use criteria such as the King's College criteria to identify patients who are unlikely to survive without a transplant.

What acute liver failure is — and what it is not

Doctors diagnose acute liver failure when three things occur together: a new, severe injury to the liver; a clotting abnormality, usually an INR of 1.5 or more; and hepatic encephalopathy — any change in mental state, from mild confusion and irritability to deep coma. By definition, the person did not have cirrhosis before (a few conditions, such as Wilson disease and autoimmune hepatitis, are exceptions to this rule when they first present this way).

It is different from acute-on-chronic liver failure, where a person with existing chronic liver disease suddenly deteriorates, and from ordinary viral hepatitis with jaundice, where the person stays alert and clotting remains near normal. Jaundice alone is not liver failure — confusion and a rising INR are the signals that it may be becoming so.

Doctors also note how quickly encephalopathy followed jaundice. In hyperacute failure (within about a week) the brain is most at risk of swelling, yet the liver often has a better chance of recovering. In subacute failure, developing over several weeks, the illness looks less dramatic but spontaneous recovery is less likely.

Causes common in India

Cause	What families should know
Hepatitis E	Spread through contaminated water, especially in the monsoon. Usually mild, but can cause liver failure, with pregnant women — particularly in the last trimester — at notably higher risk.
Hepatitis A	Common in children, usually self-limiting; adults and those with other liver conditions are more likely to become seriously ill.
Hepatitis B	A new infection, or a flare of an existing one (for example after stopping antivirals or during chemotherapy), can cause liver failure.
Anti-tuberculosis drugs	Isoniazid, rifampicin and pyrazinamide can injure the liver. Loss of appetite, vomiting or yellow eyes on TB treatment should be reported to the doctor immediately — do not simply continue.
Paracetamol	Overdose, including repeated excess doses over days, can cause severe liver injury. An antidote (N-acetylcysteine) is most effective when given early.
Herbal and indigenous medicines, supplements	A significant and under-recognised cause in India, including products marketed as liver tonics or for weight loss or bodybuilding.
Rat poison (yellow phosphorus)	Accidental or intentional ingestion of certain rodenticide pastes can cause rapid, severe liver failure; any ingestion needs hospital assessment even if the person looks well.
Wilson disease	An inherited copper disorder that can present suddenly in children and young adults as liver failure. See autoimmune and genetic liver disease.

Less common causes include mushroom poisoning, pregnancy-related liver conditions, blockage of the liver's veins (Budd-Chiari syndrome), severe infections, and autoimmune hepatitis. In a proportion of patients no cause is found despite full testing.

Warning signs — act immediately

Go to a hospital emergency department now if a person with jaundice or recent liver injury has:

confusion, unusual sleepiness, irritability or sudden change in behaviour; persistent vomiting and inability to eat; bleeding from the gums or nose, or easy bruising; very little urine; or has swallowed a large dose of paracetamol or any rat poison. Do not wait for jaundice to deepen, and do not try home or herbal remedies.

Early changes are easy to miss: a patient who sleeps through the day, is irritable at night, gives muddled answers or has a new flapping tremor of the hands may already have encephalopathy. Families who notice this should tell the doctor directly.

Why intensive care in a transplant centre, early

Acute liver failure affects the whole body. The brain can swell, blood sugar can fall dangerously, infections take hold easily, and the kidneys, lungs and circulation may fail. Patients need a liver intensive care team that can monitor these problems hour by hour — and, crucially, a transplant team that can act if the liver does not recover.

1
Intensive monitoring
Close tracking of consciousness, INR, blood sugar, kidney function, lactate and ammonia, often several times a day.
2
Treating the cause
N-acetylcysteine for paracetamol poisoning (and often for other causes in early stages), antivirals for hepatitis B, stopping every non-essential medicine and herbal product, and specific treatment for Wilson disease or pregnancy-related causes.
3
Protecting the brain and organs
Measures to limit brain swelling, careful fluids, glucose, prevention and early treatment of infection, and dialysis or ventilation if required. Some centres use plasma exchange in selected patients.
4
Early transplant assessment
The transplant team assesses the patient on arrival, while the patient can still be moved, investigated and, if needed, operated on safely.

Transferring a patient who is already in deep coma, on a ventilator, is far more dangerous and may close the window for a transplant. That is why hospitals without a liver transplant unit are advised to refer patients with rising INR and any encephalopathy early. Dr Bappaditya Har manages acute liver failure with the multidisciplinary transplant team at Narayana RN Tagore Hospital, Mukundapur, Kolkata; referring doctors and families can call 080675 06860.

King's College criteria in plain words

The King's College criteria are the most widely used rules for identifying patients who are unlikely to survive without a transplant. They are guides, not verdicts, and are always interpreted alongside the whole clinical picture. Indian centres may also use other prognostic scores developed for local causes.

After paracetamol poisoning: the blood remains too acidic despite fluids; or all three of the following — very prolonged clotting (INR above 6.5), significant kidney failure, and deep encephalopathy (grade 3 or 4).
For other causes: INR above 6.5 on its own; or any three of the following — age under 10 or over 40, an unfavourable cause (such as drug reaction or an unidentified cause), more than a week between jaundice and confusion, INR above 3.5, and a very high bilirubin.

Meeting these criteria means the chance of survival with medical treatment alone is low, and the team will usually recommend an emergency transplant if the patient is fit for one.

Emergency liver transplant

When a transplant is needed, time is measured in days. The patient is listed urgently with the state organ-sharing network under NOTTO for a deceased donor liver, where acute liver failure is given high priority. Because a suitable deceased-donor organ may not become available in time, many Indian families are also assessed for a living donor liver transplant, in which a healthy relative donates part of their liver.

Even in an emergency, the donor's safety is never compromised. The donor still undergoes full medical and psychological evaluation, and the hospital's authorisation committee under the Transplantation of Human Organs and Tissues Act must approve the donation, although this can be expedited. Donor eligibility is explained in who can be a liver donor. A blood-group mismatch does not always rule out a family donor — see ABO-incompatible liver transplant.

Outcomes after emergency transplant are generally lower than after planned transplant because the patient is critically ill, but large centres commonly report that most recipients survive and go on to lead normal lives. Some patients become too unwell for surgery — severe uncontrolled infection or irreversible brain injury are examples — which is another reason early transfer matters.

Frequently asked questions

Can a person recover from acute liver failure without a transplant?

Yes. A proportion of patients recover with intensive care alone, particularly after hepatitis A and paracetamol poisoning treated early. The liver can regenerate fully if the patient survives the acute phase. The transplant team's job is to recognise, early, those who are unlikely to recover.

How fast does acute liver failure progress?

It can progress from jaundice to coma within days. This speed is why patients with a rising INR or any confusion should be moved to a liver transplant centre early rather than observed elsewhere.

Is hepatitis E dangerous in pregnancy?

Yes. Hepatitis E is more likely to cause severe liver failure in pregnant women, especially in the third trimester. A pregnant woman with jaundice needs prompt hospital assessment.

My father's liver failed after starting TB medicines. What now?

The TB drugs are usually stopped straight away and the patient is assessed in hospital. Liver-friendly TB treatment can be restarted later under supervision. If there is confusion or the INR is rising, he needs a liver unit with transplant facilities.

How quickly can a living donor be approved in an emergency?

Evaluation and the legal authorisation can be fast-tracked, often within a short period, but no step can be skipped. Bringing identity and relationship documents for the patient and potential donors saves time.

What does an emergency liver transplant cost?

Costs depend on the illness, the donor type and the ICU stay. Please see the liver transplant cost page and speak with the transplant coordinator.

Acute Liver Failure: Causes, Warning Signs and Emergency Transplant in Kolkata