Management of Lactic Acidosis in Chronic Liver Disease

Pathophysiology and Causes

Lactic acidosis in chronic liver disease occurs due to impaired lactate clearance by the damaged liver and increased lactate production from tissue hypoxia, according to the European Association for the Study of the Liver 1, 2
Common precipitating factors include bacterial infections, GI bleeding, drug toxicity, and respiratory failure, as reported by the American Association for the Study of Liver Diseases 3, 4
Cirrhosis can lead to hemodynamic dysfunction with hypoperfusion, contributing to anaerobic metabolism and lactate production, as stated by the European Society of Anaesthesiology 5

Patients with severe lactic acidosis in chronic liver disease should be treated in intermediate care or intensive care settings, as recommended by the European Association for the Study of the Liver 3, 4
Identify and treat precipitating factors, particularly bacterial infections and GI bleeding, according to the American Association for the Study of Liver Diseases 3, 6
Monitor organ function (liver, kidney, brain, lung, coagulation, circulation) frequently as acute-on-chronic liver failure (ACLF) is a dynamic condition, as stated by the European Association for the Study of the Liver 3, 4

Monitor hemodynamic function and administer vasopressor therapy for marked arterial hypotension, as recommended by the European Society of Intensive Care Medicine 3
Norepinephrine should be the first-line vasopressor if hypotension persists after fluid resuscitation, according to the Society of Critical Care Medicine 7
Vasopressin can be added when hypotension persists despite norepinephrine use, as stated by the Society of Critical Care Medicine 7
Use crystalloids as the initial fluid resuscitation of choice, as recommended by the Society of Critical Care Medicine 7
Avoid excessive volume expansion which can worsen organ function, as warned by the European Association for the Study of the Liver 8

Provide oxygen therapy and ventilation if respiratory failure is present, as recommended by the European Association for the Study of the Liver 3
For patients with ACLF and ARDS, use low tidal volume strategy with appropriate PEEP levels, according to the Society of Critical Care Medicine 7
Special care should be taken to preserve airway patency to prevent aspiration pneumonia, as stated by the American Association for the Study of Liver Diseases 6

If kidney failure is present, identify and manage its cause accordingly, as recommended by the European Association for the Study of the Liver 3
Consider continuous renal replacement therapy (CRRT) for patients with persistent hyperammonemia, hyperkalemia, and other metabolic abnormalities, according to the Society of Critical Care Medicine 7
Early initiation of CRRT is recommended for patients with ACLF who have indications for urgent dialysis, as stated by the Society of Critical Care Medicine 7
For hepatorenal syndrome, terlipressin with albumin or norepinephrine (if terlipressin unavailable) is recommended, as suggested by the European Association for the Study of the Liver 7, 8

Treat hepatic encephalopathy with lactulose (orally or rectally) or polyethylene glycol if patients are at risk of ileus/abdominal distention, as recommended by the American Association for the Study of Liver Diseases 4
For patients with Grade 3 or 4 hepatic encephalopathy, consider ICU admission, according to the American Association for the Study of Liver Diseases 4
The use of osmotic laxatives (lactulose) to lower ammonia levels is not recommended in acute liver failure but remains standard therapy for hepatic encephalopathy in chronic liver disease, as stated by the European Association for the Study of the Liver 5, 9

Early referral to liver transplant centers for immediate evaluation is recommended for patients with ACLF, as suggested by the American Association for the Study of Liver Diseases 6
Recurrent intractable hepatic encephalopathy, together with liver failure, is an indication for liver transplantation, according to the European Association for the Study of the Liver 9
An early assessment for liver transplantation should be proposed for all patients with severe ACLF (ACLF-2 or ACLF-3), as recommended by the Society of Critical Care Medicine 7

Avoid excessive volume expansion which can worsen organ function, as warned by the European Association for the Study of the Liver 8
Do not delay transfer to a liver transplantation center when indicated, as stated by the European Society of Anaesthesiology 5
Routine measurement of ammonia levels for diagnosis of hepatic encephalopathy is not recommended, according to the American Association for the Study of Liver Diseases 4
Withdrawal of intensive care support can be considered in patients who are not candidates for liver transplantation with four or more organ failures after one week of adequate intensive treatment, as suggested by the American Association for the Study of Liver Diseases 6