Liver Failure Pathway

By Dr Chetan Kalal | DM Hepatology

A step-by-step, evidence-based pathway designed to guide patients and families through the evaluation, stabilization, and management of acute and chronic liver failure.

1. Early Identification

Liver failure is safest when detected early. Seek evaluation if there are:

• Jaundice

• Ascites (abdominal swelling)

• Confusion / sleep-wake changes

• GI bleeding

• Rapid weight loss

• Recurrent hospitalizations

• Worsening sugars or kidney function

Early hepatology review improves survival.

2. Initial Assessment (Outpatient / ER)

Dr Kalal performs a structured evaluation including:

• LFT, INR, bilirubin, ammonia

• Kidney profile, electrolytes

• Ultrasound + FibroScan

• Viral markers (HBV/HCV)

• Autoimmune & metabolic screening

• Alcohol-related liver disease assessment

• MELD score for disease severity

The goal: Identify the type and stage of liver failure quickly.

3. Risk Stratification

Patients are categorized into:

• Compensated Cirrhosis (stable)

• Decompensated Cirrhosis (ascites, variceal bleed, encephalopathy)

• ACLF (Acute-on-Chronic Liver Failure)

• Acute Liver Failure (rapid deterioration, high-risk)

This determines whether you need urgent IPD care or outpatient management.

4. Stabilization & IPD Management

For decompensated or ACLF cases, hospital care may involve:

• Fluid & sodium management

• IV antibiotics for infections

• Lactulose / rifaximin for encephalopathy

• Paracentesis for ascites

• Variceal bleed control (banding/TIPS)

• Renal protection strategies

• Nutritional & sarcopenia management

• Alcohol cessation protocols (if applicable)

Aim: Stabilize, reverse triggers, and improve transplant readiness.

5. Transplant Candidacy Evaluation

If liver reserves are low, Dr Kalal performs:

• MELD-based transplant need assessment

• Imaging for HCC

• Cardiac & pulmonary fitness tests

• Frailty and nutritional evaluation

• Infection clearance

• Family/donor counselling

Clear, transparent discussion:
Is transplant needed? Is it urgent? What options exist?

6. Decision Pathway

Based on all assessments, patients are guided into one of:

A. Medical Optimization Pathway

For patients who can recover without transplant.
Includes fibrosis slowdown, ascites control, metabolic reversal, nutritional rebuild.

B. Early Transplant Planning

For high MELD, recurrent hospitalizations, HCC within criteria.

C. Urgent Transplant Listing

For ACLF or rapidly deteriorating cases.

7. Transplant Coordination (If Required)

Dr Kalal coordinates with accredited transplant centres for:

• Donor evaluation

• Living / deceased donor pathways

• Surgical planning

• Perioperative ICU care

• Seamless cross-team communication

8. Post-Stabilization Follow-up

Regular monitoring includes:

• LFT, INR, renal and electrolyte panels

• Ascites and encephalopathy control

• Muscle mass, nutrition and sarcopenia reversal

• Infection prevention

• HCC surveillance

Objective: Prevent re-decompensation and maintain long-term stability.

9. Post-Transplant Pathway (If Transplanted)

Comprehensive follow-up:

• Immunosuppression optimisation

• Rejection monitoring

• Renal protection

• Metabolic management

• Long-term cancer surveillance

Why This Pathway Matters

• Reduces repeated hospitalizations

• Improves quality of life

• Identifies transplant need at the right time

• Predicts risk and prevents complications

• Creates clarity for patients and families

Book a Liver Failure Evaluation

• Global Virtual Consults: Available
  Website: drchetankalal.com