When the heart kills the liver: acute liver failure in congestive heart failure

Although the pathophysiology is poorly understood, there is rising evidence, that low cardiac output with consecutive reduction in hepatic blood flow is a main causing factor, rather than hypotension. In the setting of acute liver failure due to congestive heart failure, clinical signs of the latter can be absent, which requires an appropriate diagnostic approach.As a reference center for acute liver failure and liver transplantation we recorded from May 2003 to December 2007 202 admissions with the primary diagnoses acute liver failure. 13/202 was due to congestive heart failure, which was associated with a mortality rate of 54%. Leading cause of death was the underlying heart failure. Asparagine transaminase (AST), bilirubin, and international normalized ratio (INR) did not differ significantly in surviving and deceased patients at admission. Despite both groups had signs of cardiogenic shock, the cardiac index (CI) was significantly higher in the survival group on admission as compared with non-survivors (2.1 L/min/m2 vs. 1.6 L/min/m2, p = 0.04). Central venous - and pulmonary wedge pressure did not differ significantly. Remarkable improvement of liver function was recorded in the group, who recovered from cardiogenic shock.In conclusion, patients with acute liver failure require an appropriate diagnostic approach. Congestive heart failure should always be considered as a possible cause of acute liver failure.Acute liver failure (ALF) is defined as an abrupt onset of jaundice, hepatic encephalopathy, and coagulopathy in the absent of pre-existing liver disease [11]. Cardiomyopathy as the underlying cause of ALF is rare and only a few case reports are documented in the literature [5,7,8,18]. Cardiac decompensation can initially be undetected, and the usual signs of congestive heart failure may be absent [5,18]. Both, chronic and acute congestive heart failure can lead to hepatic dysfunction [10,17]. Although there is no classic pattern of abnormalities, a cholesta