Suspected Acute Liver Failure
INR ≥1.5 + encephalopathy + no prior liver disease + illness <26 weeks
All Pathways
GastroenterologyEmergency
Acute Liver Failure Management (AASLD 2023)
Acute Liver Failure Management (AASLD 2023): Suspected Acute Liver Failure → ICU Admission & Stabilization → Determine Etiology → Grade of Hepatic Encep...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action ICU Admission & Stabilization
Immediate ICU care essential
- Contact transplant center EARLY
- Central line, arterial line
- Avoid sedation if possible (mask encephalopathy)
- Head of bed 30 degrees
03Action Determine Etiology
Cause determines treatment and prognosis
- Acetaminophen level (even if >24h)
- Viral hepatitis panel (HAV, HBV, HEV)
- Autoimmune markers (ANA, ASMA, IgG)
- Wilson's disease (ceruloplasmin, 24h urine Cu)
- Drug/toxin history
- Pregnancy test (AFLP, HELLP)
04Decision Grade of Hepatic Encephalopathy
Assess West Haven criteria
- Grade 1: Mild confusion, sleep disturbance
- Grade 2: Drowsy, inappropriate behavior
- Grade 3: Somnolent but arousable, confused
- Grade 4: Coma, unresponsive
05Action Grade 1-2 HE
Close monitoring, avoid precipitants
- Lactulose to achieve 2-3 BM/day
- Avoid sedatives/opioids
- Correct metabolic derangements
- Frequent neuro checks
06Decision Transplant Evaluation
Apply King's College Criteria or other prognostic scores
- APAP: pH <7.3 OR (INR >6.5 + Cr >3.4 + Grade 3-4 HE)
- Non-APAP: INR >6.5 OR any 3 of: age <10 or >40, non-A/B hepatitis, drug toxicity, jaundice >7d before HE, INR >3.5, bilirubin >17.5
07Action List for Transplant (Status 1A)
Poor prognosis criteria met
- UNOS Status 1A listing
- Continue supportive care
- Bridging therapies (plasmapheresis, MARS) if available
- Liver support devices if available
08Outcome Liver Transplantation
1-year survival ~80% post-transplant
09Action Supportive Care & Monitoring
May recover with medical management
- Correct coagulopathy only if bleeding
- Avoid prophylactic FFP (masks prognosis)
- Glucose monitoring (hepatic gluconeogenesis impaired)
- Renal replacement therapy if needed
- Infection surveillance
10Outcome Spontaneous Recovery
~40-50% of non-transplanted patients survive with supportive care
11Warning ⚠️ Grade 3-4 HE (High Risk)
Risk of cerebral edema
- Intubate for airway protection
- Consider ICP monitoring
- Mannitol 0.5-1 g/kg for ICP crisis
- Hypertonic saline target Na 145-150
- Avoid hyperthermia
- Path rejoins step 06Shared downstream outcome
12Decision N-Acetylcysteine (NAC)
Indicated for acetaminophen AND may benefit non-APAP ALF
13Action IV NAC Protocol
21-hour IV protocol (preferred)
- 150 mg/kg over 1 hour
- 50 mg/kg over 4 hours
- 100 mg/kg over 16 hours
- Continue until INR <2 and encephalopathy resolving
- Path rejoins step 04Shared downstream outcome
Guideline Source
AASLD Position Paper: The Management of Acute Liver Failure: Update 2023
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Requires ICU-level care
- Transfer to transplant center should be early
- NAC dosing protocol specific for acetaminophen
- Cerebral edema monitoring may require invasive monitoring
- King's College Criteria has limitations - use with clinical judgment
Applicable Regions
USEUGlobal
EU: EASL guidelines are similar
US: AASLD 2023 is current standard
Version 1Next review: 2027-01-01
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Frequently Asked Questions
What is the Acute Liver Failure Management (AASLD 2023)?
The Acute Liver Failure Management (AASLD 2023) is a emergency clinical algorithm for Gastroenterology. It provides a structured decision tree to guide clinical decision-making, based on AASLD Position Paper: The Management of Acute Liver Failure: Update 2023.
What guideline is the Acute Liver Failure Management (AASLD 2023) based on?
This algorithm is based on AASLD Position Paper: The Management of Acute Liver Failure: Update 2023 (DOI: 10.1002/hep.32766).
What are the limitations of the Acute Liver Failure Management (AASLD 2023)?
Known limitations include: Requires ICU-level care; Transfer to transplant center should be early; NAC dosing protocol specific for acetaminophen; Cerebral edema monitoring may require invasive monitoring; King's College Criteria has limitations - use with clinical judgment. Individual patient factors may require deviation from these recommendations.
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