Acute Liver Failure: Review and Update

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Acute liver failure (ALF) combines the clinical features of an acute severe insult to a previously normal liver with the development of progressive hepatic encephalopathy, coagulopathy, and jaundice, and the potential to rapidly progress to multiorgan failure.1–3 In those with severe hepatic encephalopathy, progression to cerebral edema (CE) and intracranial hypertension (ICH) is a feared outcome, often with fatal consequences.4,5 ALF is rare, with an incidence in the developed world of probably <5 cases per million population per year.6–8
This disease’s rarity, severity, and phenotypic heterogeneity combine to result in a uniquely challenging illness, both in relation to its study and in relation to the development of effective treatments. Few specific interventions have been tested in controlled trials, with most supportive care and decision-making strategies evolving from analysis of natural history data, with extrapolation from other critical illnesses.1,9,10 Nonetheless, a complex package of supportive critical care is now delivered, and there is evidence of the increasing success of this approach. Further, evidence is also emerging that over time there have been other fundamental changes in the nature and severity of the illness. These changes have mandated a reappraisal of key aspects of the care of ALF patients. This chapter will review this evidence, summarize how this impacts upon current care of patients with ALF, and speculate upon how care will further evolve.

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