Liver failure: symptoms, cause, treatment and prognosis

Liver failure (hepatic insufficiency) is a serious deterioration of liver functions. What is liver failure and how is liver failure treated? One speaks of ‘liver failure’ when the liver is not functioning properly in all these processes. Due to the loss of functional cells, the total effective liver volume falls below a critical limit. As a result, a large number of toxins accumulate in the body. As a result, the brain and other organs are affected. Liver failure can occur both acutely (i.e. sudden liver failure) and chronically (i.e. liver function that deteriorates over time). The liver is located in your upper right abdomen, just behind the ribs and fulfills many essential functions in the human body. The liver detoxifies the blood and produces numerous proteins and hormones. The liver also plays a role in the immune system.

  • What is liver failure?
  • Causes of liver failure
  • Causes of chronic liver failure
  • Causes of acute liver failure
  • Symptoms of liver failure
  • First symptoms of liver failure
  • Later symptoms liver failure
  • Complications
  • Examination and diagnosis
  • History and physical examination
  • Liver function examination
  • Visual art investigation
  • Examination of liver tissue
  • Treatment of liver failure
  • Medications for acute liver failure
  • Liver transplant
  • Chronic liver failure
  • Prevention
  • Prognosis


What is liver failure?

Liver failure means that the liver is not functioning properly. Liver failure occurs when large parts of the liver become irreparably damaged, making the liver no longer able to function and liver functions are disrupted. Two forms of liver failure are distinguished: acute liver failure and chronic liver failure. When liver failure occurs suddenly it is referred to as ‘acute liver failure’ and when liver failure develops over a longer period of time it is referred to as ‘chronic liver failure’. Acute liver failure is a life-threatening condition that requires immediate medical attention. Usually, liver failure develops gradually over many years (chronic liver failure).

Excessive alcohol consumption / Source: Deli

Causes of liver failure

Causes of chronic liver failure

The most common causes of chronic liver failure (where the liver functions worse over months to years) are:

  • Hepatitis B
  • Hepatitis C
  • Long-term excessive alcohol use
  • Cirrhosis
  • Hemochromatosis (a hereditary condition in which too much iron is absorbed from the normal diet)
  • Malnutrition


Paracetamol overdose can lead to liver failure / Source: Martin Sulman

Causes of acute liver failure

The most common causes of acute liver failure are:

  • Hepatitis viruses, such as hepatitis A, B, C, D and E. Other viruses that can cause acute liver failure, such as the Epstein-Barr virus (best known as the cause of mononucleosis, also called glandular fever due to swollen glands), cytomegalovirus and the herpes simplex virus, are less common.
  • Medications (e.g. paracetamol, antibiotics, non-steroidal anti-inflammatory drugs and anti-epileptic drugs).

Paracetamol can be harmful after overdose. Liver damage can occur after taking a single dose of 10 to 15 grams of paracetamol. Furthermore, it appears that daily use of the normal dosage can ultimately lead to liver damage.[1]

Fatigue / Source:

Symptoms of liver failure

First symptoms of liver failure

The first symptoms of liver failure are often non-specific (i.e. they can also indicate other conditions), making liver failure initially difficult to diagnose. Early symptoms include:

  • Nausea
  • Vomit
  • Loss of appetite
  • Fatigue
  • Diarrhea


Later symptoms liver failure

Later in the disease process, the symptoms become more serious and you may experience the following complaints:

  • Jaundice
  • Swollen abdomen
  • Difficulty concentrating, disorientation, mental confusion, apathy, memory impairment, drowsiness/sleepiness, hand trembling (known as ‘hepatic encephalopathy’, a condition in which brain function is affected by the build-up of toxins in the blood due to failure of the liver to remove them, which ultimately results in a coma if timely intervention is not taken)
  • Clotting disorders (an abnormality in the system that controls blood clotting)
  • Kidney failure or renal insufficiency and ultimately multi-organ failure, causing an oxygen deficiency in the organs, causing them to function worse


Location of the liver / Source: Nerthuz/


Liver failure can cause the following complications:

  • Cerebral edema: A swelling of the brain, a potentially life-threatening condition that may require prompt medical intervention.
  • Bleeding disorders or excessive bleeding: An abnormal liver cannot produce sufficient amounts of clotting factors. People with acute liver failure often develop bleeding in the gastrointestinal tract. These bleedings can be difficult to treat.
  • Infections: People with acute liver failure are at increased risk of developing a variety of infections, especially in the blood, respiratory and urinary tracts.
  • Kidney failure: this often occurs after liver failure, especially with paracetamol overdose. That damages both your liver and your kidneys.


Examination and diagnosis

History and physical examination

It is wise to contact your doctor as soon as possible if you develop complaints about your liver or symptoms that indicate liver failure. Liver failure is a serious condition that is potentially life-threatening. Rapid diagnosis and treatment is beneficial for the prognosis. The doctor will have an extensive interview with you (anamnesis) about your complaints and lifestyle and will also take your medical history into account. An extensive physical examination will then take place. The diagnosis can be considered based on the complaints you experience and the physical examination.

Collection of blood for research / Source:

Liver function examination

Liver function testing takes place. This is a blood test for the different functions of the liver. Blood tests show, among other things:

  • increased levels of liver enzymes and bilirubin (liver values);
  • abnormal blood clotting values;
  • reduced protein (albumin) levels in the blood;
  • an increase in the level of ammonia (waste product) in the blood.


Visual art investigation

Imaging tests such as ultrasound or a CT scan of the abdomen may be necessary to examine your liver. Imaging research shows abnormalities in the liver, an enlarged spleen and possibly ascites (water belly).

Examination of liver tissue

the doctor may need to remove a small piece of liver tissue (liver biopsy) for examination under the microscope. Microscopic examination of liver tissue can confirm the diagnosis.

Hospital admission / Source:

Treatment of liver failure

The most important aspect of treatment in patients with acute liver failure is admission to a department where intensive care is possible with close monitoring so that complications can be prevented.

Medications for acute liver failure

In acute liver failure, medications can be administered to prevent poisoning. Acute liver failure caused by a paracetamol overdose is usually treated with activated charcoal if the paracetamol has been taken within the previous few hours. When the concentration of paracetamol in the blood is high, acetylcysteine is often given (orally or intravenously) to reduce the toxic effect of paracetamol.

Liver transplant

When the liver is damaged for more than 70%, the chances of survival are small and a liver transplant is often the appropriate treatment. In this procedure, the damaged liver is removed and replaced with a healthy liver from a donor. In 2023, there are three liver transplant centers in the Netherlands: Erasmus MC Rotterdam, LUMC Leiden and UMC Groningen. In the Netherlands, the UMCG is the transplant center for children.

Liver transplant centers in the Netherlands

A. Erasmus MC Rotterdam
B. LUMC Leiden
C. UMC Groningen


Chronic liver failure

Whenever possible, the underlying condition causing the liver failure is treated. Furthermore, the use of medications or other substances that are toxic to the liver will be discontinued. You should give up alcohol. In chronic liver failure, treatment will mainly focus on preventing further deterioration of the liver.

Healthy nutrition is important for a healthy liver / Source: Oleksandra Naumenko/Shutterstock


The best way to prevent liver failure is to limit the risk of liver cirrhosis or hepatitis. Here are some tips to prevent these conditions:

  • Vaccination against hepatitis A: this is done with an inactivated hepatitis A vaccine.
  • Vaccination against hepatitis B: this is given to groups of people who are more likely to be infected with the hepatitis B virus. It is also one of the vaccinations in the National Vaccination Program.
  • Eat healthy and varied. Some foods fit into a diet to support or detox your liver.
  • Drink alcohol in moderation or preferably not at all. Avoid alcohol when taking paracetamol.
  • Be attentive to hygiene. Since germs are often spread by hands, it is wise to wash your hands thoroughly after going to the toilet. Also wash your hands before touching food.
  • Do not touch blood or blood products.

Vaccination / Source: Production Perig/

  • Do not share personal toiletries, such as toothbrushes and razors.
  • If you get a tattoo or piercing, make sure it is done under hygienic conditions and that the equipment is aseptic (i.e. free of disease-causing microorganisms).
  • Make sure you use condoms when you have sex. The safest thing is to only have sex within a monogamous relationship with one partner for your entire life.
  • If you inject drugs, do not share syringes with others.



The prognosis depends on the cause of liver failure. Acute liver failure is unpredictable and has a high morbidity and risk of mortality. Early and accurate diagnosis and adequate treatment are important for a more favorable prognosis. An important factor in determining the prognosis is the cause of liver failure. Paracetamol overdose, hepatitis A, ischemia (reduction or interruption of blood supply to an organ or tissue), and pregnancy, are associated with at least 60% short-term survival without transplantation. Idiosyncratic drug-induced liver injury, hepatitis B, autoimmune hepatitis (AIH), and undetermined causes are associated with approximately 30% spontaneous survival.

  1. Kaplowitz N. Acetaminophen hepatoxicity: what do we know, what don’t we know, and what do we do next? Hepatology 2004;40:23–6.


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