Acute hepatic injury with impaired synthetic function and encephalopathy requiring immediate etiologic treatment, cerebral-edema prevention and early transplant-center involvement.
Classic acute liver failure is acute liver injury with coagulopathy (commonly INR ≥1.5) and hepatic encephalopathy in a patient without established cirrhosis. Immediately distinguish ALF from acute-on-chronic liver failure, sepsis-associated cholestasis and isolated drug-induced transaminitis.
Obtain a careful drug/toxin history, acetaminophen level, viral/autoimmune testing and vascular imaging as appropriate. Give N-acetylcysteine promptly for acetaminophen toxicity and consider it early in selected non-acetaminophen ALF according to specialist/local protocols; treat other reversible causes specifically when identified.
Discuss/transfer to a liver-transplant center early rather than waiting for advanced multiorgan failure. Serially reassess encephalopathy, INR, lactate, bilirubin, renal function, glucose, ammonia and hemodynamics alongside validated prognostic/transplant criteria.
Caution
The major time-sensitive decision in ALF is early transplant-center escalation. Waiting for irreversible multiorgan failure before referral can remove the window for transplantation.
Current acute-liver-failure diagnostic, etiologic and ICU management guidance.
Current transplant-candidate evaluation and early referral framework.
Evidence status
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