Acute liver failure: Early referral is the key

Acute liver failure (ALF) is a rare but devastating condition which requires immediate recognition and management in experienced centers. The etiology of this syndrome is most frequently drug toxicity, with acetaminophen on top of the list, and acute viral hepatitis declining over the years. This condition is rapid and unpredictable, and the outcome is related to the etiology (acetaminophen and Hepatitis A, better than other drugs and Hepatitis B, and Wilson's disease the worst) and the degree of liver damage and hepatic encephalopathy at the time of presentation. Management includes supportive care in intensive care units, and specific treatments in certain conditions, such as delivery for acute fatty liver of pregnancy, N-Acetylcysteine for acetaminophen overdose, and silibinin for mushroom poisoning, among others. Liver transplantation is the standard of care for patients with a low chance of spontaneous survival. Bridging techniques with liver support devices are still experimental and none have proven benefit to date. A randomized controlled trial of N-Acetylcysteine for non-acetaminophen ALFs is underway. Early referral to experienced centers, and centers where liver transplant is available, is the key to improve outcome.