Causes Of Death In Liver Cirrhosis: Timeline And Stages

Cirrhosis is a major worldwide public health problem. In the United States, cirrhosis currently affects nearly one in 50 adults and causes more than 50,000 deaths each year. Cirrhosis is one of the top ten causes of death in adults worldwide.¹ ²

Over time, the progression of cirrhosis leads to chronic and often irreversible liver failure, which can be fatal. While liver failure often occurs slowly over time, several factors can also cause sudden liver failure and, without rapid medical intervention, potentially lead to death.

Liver failure

Liver failure occurs when a large portion of the liver becomes damaged and can no longer function properly. Liver failure can cause a variety of problems, including:

• preventing the liver from processing nutrients, hormones, drugs, and natural toxins, which can lead to these substances building up in the blood

• reducing the levels of many beneficial substances produced and secreted by the liver, such as bile, or proteins needed for blood clotting

• impairing the flow of blood through the liver

Liver failure often develops gradually over a long period. This is known as chronic liver disease. However, liver failure can also develop more suddenly, which is known as acute liver disease. Both types can potentially lead to death. 

Types of liver failure

There are two main types of liver failure: chronic and acute. Both have a different timeline that describes how they develop. 

Chronic liver failure

Chronic liver failure, also known as end-stage liver disease, develops slowly, generally over months to years.

The main stages of chronic liver failure are:

1. Inflammation: Following liver injury, the liver responds by becoming swollen and inflamed.

2. Fibrosis: As the liver tries to repair the damage, it develops scars that can reduce the functioning of the liver.

3. Cirrhosis: When the scarring of the liver worsens and continues to reduce the function of the liver. At this point, the damage is generally considered irreversible. 

4. End-stage liver failure: The severe stage in which major complications often develop, which generally leads to death. 

It’s also possible to develop acute-on-chronic liver failure. This is when someone has chronic liver failure but suddenly experiences a rapid decline in their liver function, making it resemble acute liver failure.

Acute liver failure

Acute liver failure, sometimes known as fulminant hepatic failure, occurs quickly and usually develops over days to weeks. Acute liver failure is less common than chronic liver failure. 

It often occurs in people who don’t have pre-existing liver disease. However, a person who already has chronic liver disease can still develop acute liver failure.

Acute liver failure is a medical emergency that can be life-threatening without urgent medical treatment.

Causes of chronic liver failure

Chronic liver failure occurs gradually over many years. When the liver experiences damage, the tissue becomes inflamed. If this inflammation continues, then scar tissue will begin to form and gradually build up over time. Cirrhosis occurs when there is so much scar tissue that it impedes liver function.

This scarring is generally permanent, and cirrhosis is considered to be a fatal condition. Although people with mild cirrhosis can survive for many years, most cases of cirrhosis progress and eventually cause death. 

Deaths due to late-stage liver cirrhosis are increasing worldwide. Liver failure affects many other organ systems throughout the body, and these effects can be severe and lead to death.

Cirrhosis, and subsequently liver failure, can be caused by:

Excessive alcohol intake

Excessive alcohol intake over a long period can cause cirrhosis and liver failure. When liver cells break down alcohol, certain toxic chemicals are formed. These cause damage to the liver cells, leading to inflammation.

Excessive and chronic alcohol use is thought to account for around 25% of all deaths due to cirrhosis in adults. The risk of developing cirrhosis from alcohol is increasing, especially in people under 45, which is believed to be due to increased alcohol intake.³

Chronic hepatitis infections

Certain viruses, including hepatitis B and C viruses, can cause chronic infections in the liver. These infections can lead to liver cirrhosis and death. One study found that around 29% of all mortality cases of cirrhosis were caused by a hepatitis B infection.⁴

Some studies report that cirrhosis deaths due to viral hepatitis are declining each year, especially in developed countries, due to preventative measures such as vaccinations for the hepatitis B virus.⁵

Genetic diseases

Certain genetic diseases can cause cirrhosis. Some of these include:

• Wilson’s disease: A condition that causes too much copper to build up in the body, damaging the liver. 

• Hereditary hemochromatosis: A condition that causes too much iron to build up in the body, including in the liver, leading to damage. 

• Alpha-1 antitrypsin deficiency: A condition that results in a lack of the enzyme alpha-1 antitrypsin.

Non-alcoholic fatty liver disease

In people with non-alcoholic fatty liver disease (NAFLD), there is a build-up of fat in the liver. This disease can also be called non-alcoholic steatohepatitis (NASH).

In some instances, fatty liver can be caused by excessive alcohol use. However, it can also be caused by other lifestyle factors, such as obesity, diabetes, abnormal cholesterol levels, metabolic syndrome, and genetics. Over time, NAFLD leads to inflammation and scarring in the liver.

This disease accounts for almost 8% of all deaths due to liver cirrhosis in men and 11% in women. Deaths from NAFLD are currently less common than those due to alcohol and viral hepatitis, but they are predicted to increase.

Bile duct disorders

Bile duct disorders can lead to inflammation and scarring in the liver, causing cirrhosis and liver failure. In these conditions, bile is unable to be secreted from the liver and builds up in the organ, leading to scarring.

Causes of acute liver failure

Although liver failure often develops slowly over many years, it can also come on suddenly. This is known as acute liver failure. Some causes of acute liver failure include:

Drug-induced acute liver injury

An excessive intake of certain medications can cause acute liver failure, such as:

• Over-the-counter medications, especially anti-inflammatory drugs like acetaminophen (Tylenol)

• Prescription medications, such as:

• certain antibiotics

• antidepressants

• anti-seizure medications

• hormone replacements

• antifungals

• some dietary supplements and herbs (including kava, ephedra, skullcap, and pennyroyal)

• weight loss medications

Medical conditions

Several medical conditions can cause acute liver failure. Some of these conditions can also be causes of chronic liver failure. 

These include:

• Wilson’s disease

• Autoimmune hepatitis

• Epstein-Barr virus

• Cytomegalovirus

• Herpes simplex virus   

• Cancer that spreads to the liver

Ingesting toxins

Ingesting certain toxins can lead to acute liver failure. Some examples of such toxins are:

• Poisonous mushrooms, such as Amanita phalloides

• Industrial chemicals, such as carbon tetrachloride

Heat stroke

Heat stroke can cause multiple organs in the body to fail. In rare instances, heat stroke can cause acute liver failure.

Septic shock

Septic shock is a life-threatening condition caused by an infection. It causes multiple organs to fail rapidly, including the liver, due to reduced blood flow to these organs.

The risk of death is high. This condition may be a cause of death in people who already have cirrhosis or liver disease or in people who don’t have any prior problems with the liver.

Complications of liver failure

Cirrhosis and liver failure can lead to several complications that have the potential to result in death. Some possible complications of liver failure include:

Variceal bleeding

Varices are abnormally dilated veins in the esophagus, which develop when scar tissue blocks blood flow to the liver. Because of the obstruction of blood flow, the pressure rises in these veins, which causes them to become enlarged. Varices can rupture, resulting in severe bleeding. 

Ruptured varices are a very serious complication. They are one of the major causes of death in people with cirrhosis.

Ascites

Ascites is swelling in the abdomen due to a build-up of fluid. It can cause symptoms like bloating, nausea, swelling, shortness of breath, and swelling in the lower legs. Severe liver disease is one of the leading causes of ascites.

Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis is an infection that develops in the fluid in the abdomen, which is usually related to ascites. It is a common cause of death in people with cirrhosis. Symptoms can include fever, chills, abdominal pain, and confusion.

Hepatorenal syndrome

Hepatorenal syndrome is kidney failure that is caused by advanced liver disease. When the liver is not functioning well, this also affects the kidneys’ ability to function. Symptoms of kidney failure can include nausea, itchiness, fatigue, inability to concentrate, and chest pain.⁶

Hepatorenal syndrome is a life-threatening complication that occurs in around half of people with liver failure. It can lead to death, as toxic substances build up in the blood when the kidneys fail.

Hepatopulmonary syndrome

Hepatopulmonary syndrome is a condition that develops when liver disease causes low oxygen levels in the blood. It occurs because changes in blood flow through the liver can also alter blood flow through the lungs, which makes the lungs unable to oxygenate the blood well enough.⁷

Shortness of breath, blue lips and skin, and rounding of the ends of the fingers are key symptoms.

Treatments available for liver failure

Liver failure can’t always be reversed. However, it may be possible to control the symptoms and prevent further progression of liver damage.

The recommended treatment depends on whether the liver failure is acute or chronic and what has caused it.

Treating the cause of the disease and liver failure

In both acute and chronic liver failure, it’s important to treat the underlying cause of the damage.

For chronic liver failure and cirrhosis, this may include:

• avoiding drinking alcohol, if the liver failure is caused by alcoholic liver disease 

• losing weight, if the liver failure is caused by non-alcoholic fatty liver disease

• eating a healthy diet 

• taking medications to treat hepatitis 

Acute liver failure may require additional immediate treatment, such as:

• taking medications to treat poisoning

• blood transfusions with clotting proteins to prevent bleeding

• a breathing tube or mechanical ventilator to assist with breathing 

Any complications of liver failure that are present must also be treated.

Liver transplant

If the liver has become damaged to the point that it can no longer recover, then a liver transplant is the only way to save the patient’s life. A liver transplant can significantly prolong survival. Unfortunately, because there aren’t enough donor livers available for everyone who would benefit from one, not all eligible patients are able to receive a liver transplant.

Palliative or hospice care

People who have end-stage liver failure may need palliative or hospice care to provide them with support. This type of care focuses on the quality of life rather than attempting to lengthen life. 

End-stage liver disease symptoms before death

Some of the symptoms that a person with end-stage liver disease may experience before death include:

• Fatigue

• Itching

• Build-up of fluid in the extremities, especially the legs and feet

• Swelling in the abdomen 

• Shortness of breath

• Abdominal pain, especially in the upper right part of the abdomen (where the liver is located)

• Jaundice — a condition where the skin and the whites of the eyes turn yellow due to a build-up of bilirubin, a substance that the healthy liver helps to remove

• Nausea

• Vomiting, which may include vomiting up blood

• Loss of appetite

• Blood in the stool

• Drowsiness, severe confusion, or difficulty concentrating

The lowdown

Liver failure occurs when the liver is not able to carry out its normal functions. It has many potential causes. Liver failure can be chronic (long-term) or acute (short-term).

If you are concerned about your liver function, it’s recommended that you see your doctor as soon as possible. Getting an early diagnosis of liver disease can help prevent it from progressing to liver failure. Without medical intervention, both acute and chronic liver failure can cause death.

Frequently asked questions

How do you know death is near with liver failure?

Someone with liver failure who is nearing death is described as having end-stage liver disease. This can cause symptoms such as jaundice, confusion and uncertainty, severe tiredness, a build-up of fluid in the abdomen, shortness of breath, and bleeding easily.

How long does liver failure last before death?

The life expectancy of someone with liver failure depends on whether the liver failure is acute or chronic and how advanced the liver failure is.

Acute liver failure develops suddenly, so death may occur quickly unless the patient receives rapid treatment. Chronic liver failure develops slowly over a much longer period. Once complications have developed, about 85% of patients die within five years.⁸

What happens when someone is dying from liver failure?

Liver failure describes the point where the liver isn’t able to carry out its functions that are essential to survival. This includes removing toxins from the bloodstream, producing proteins for clotting, and making and secreting bile. When the liver can’t perform these functions, symptoms like confusion, excessive bleeding and bruising, and fluid build-up in the abdomen will occur. 

How can I test my liver function at home?

Blood tests, known as liver function tests, are used to assess how well your liver is functioning. It’s possible to order a liver function test kit delivered to your home and send a blood sample to a lab. However, if you have concerns about your liver function, it’s always best to see a doctor to get a comprehensive professional evaluation.

Can a damaged liver repair itself?

In the early stages, a damaged liver can repair and regenerate itself by developing new cells. However, once too much scar tissue has built up, then the liver can no longer repair itself effectively. This is known as cirrhosis.