Acute liver failure

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 3 Aug 2025

Last updated: 31 Dec 2024

Acute liver failure is a rare, life-threatening, potentially reversible condition defined by jaundice, coagulopathy, and hepatic encephalopathy.

Occurs in patients with no preexisting liver disease and may result in severe liver impairment and rapid clinical deterioration.

The etiology and the interval from onset of jaundice to the development of encephalopathy have a significant impact on prognosis.

Etiology is established by history, serological assays, and exclusion of alternative causes, including acute presentations of chronic liver diseases.

Treatment involves intensive care unit monitoring, specific therapies based on etiology, and management of known complications.

All patients should be considered for possible liver transplantation.

Prognostic models may be used to assess the probability of spontaneous recovery and are instrumental in selection of patients who should potentially undergo liver transplantation.

Definition

Acute liver failure (ALF) is a rare, life-threatening, potentially reversible condition with a rapid decline in hepatic function characterized by jaundice, coagulopathy (INR >1.5), and hepatic encephalopathy in patients with no evidence of prior liver disease.[1][2][3][4]

If these symptoms occur in a patient with preexisting liver disease, the term acute-on-chronic liver failure is used, and is considered a separate diagnosis from ALF.[4][5]

ALF may be classified as hyperacute, acute, or subacute, depending on the interval from the onset of jaundice to the development of encephalopathy.[3][4][6]

The term acute liver failure is preferred over fulminant hepatic failure or acute hepatic necrosis, although these terms have been used historically to classify hepatic failure.[1][2][7]

History and exam

Key diagnostic factors

hepatotoxic drugs
chronic alcohol misuse
pregnancy
jaundice
coagulopathy
signs of hepatic encephalopathy

Full details

Other diagnostic factors

absence of history of chronic liver disease
abdominal pain
nausea
vomiting
malaise
signs of cerebral edema
right upper quadrant tenderness
hepatomegaly
absence of splenomegaly
absence of spider angiomata
absence of palmar erythema
absence of ascites
depression or suicidal ideation
Wilson disease
exposure to hepatotoxins
illicit drug use
absence of malignancy

Full details

Risk factors

chronic alcohol misuse
poor nutritional status or fasting
female sex
age >40 years
pregnancy
chronic hepatitis B
chronic pain and narcotic use
herbal and dietary supplement hepatotoxicity
Wilson disease
acetaminophen and antidepressant therapy
chronic hepatitis C
HIV and hepatitis C coinfection

Full details

Diagnostic tests

1st tests to order

liver function tests
prothrombin time/INR
viscoelastic testing (VET)
basic metabolic panel
CBC
blood type and screen
serum amylase and lipase
arterial blood gas
arterial blood lactate
acetaminophen level
urine toxicology screen
viral hepatitis serologies
autoimmune hepatitis markers
pregnancy test
chest x-ray
abdominal ultrasound with Doppler

Full details

Tests to consider

factor V level
viral hepatitis polymerase chain reaction (PCR) studies
serum ceruloplasmin
serum copper
24-hour urinary copper excretion
slit-lamp ophthalmologic examination
arterial ammonia
HIV test
urinalysis and urine sodium
surveillance cultures
Coombs test
biomarkers
liver biopsy
CT scan of head
CT/MR cholangiography
transcranial Doppler

Full details

Treatment algorithm

ACUTE

all patients

Contributors

Authors

Stevan A. Gonzalez, MD, MS

Associate Professor

Department of Internal Medicine

TCU and UNTHSC School of Medicine

Medical Director of Liver Transplantation

Annette C. and Harold C. Simmons Transplant Institute

Baylor All Saints Medical Center

Fort Worth

Disclosures

SG is a paid consultant and speaker for Mallinckrodt Pharmaceuticals.

Acknowledgements

Dr Stevan Gonzalez would like to gratefully acknowledge the late Dr Emmet B. Keeffe who previously co-contributed to this topic; an esteemed colleague, friend, and mentor.

Disclosures

EBK declared that he had no competing interests.

Peer reviewers

Timothy J. Davern, MD

Director of Acute Liver Failure Program

California Pacific Medical Center Liver Transplant Program

San Francisco

Disclosures

Not disclosed.

Muhammad Dawwas, MRCP

Specialist Registrar

Liver Unit

Addenbrooke's Hospital

Cambridge

Disclosures

Not disclosed.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Shingina A, Mukhtar N, Wakim-Fleming J, et al. Acute liver failure guidelines. Am J Gastroenterol. 2023 Jul 1;118(7):1128-53.Full text Abstract

Lee WM, Squires RH Jr, Nyberg SL, et al. Acute liver failure: summary of a workshop. Hepatology. 2008 Apr;47(4):1401-15.Full text Abstract

American Association for the Study of Liver Diseases. AASLD position paper: the management of acute liver failure: update 2011. Nov 2011 [internet publication].Full text

Wendon J, Cordoba J, Dhawan A, et al; European Association for the Study of the Liver. EASL clinical practical guidelines on the management of acute (fulminant) liver failure. J Hepatol. 2017 May;66(5):1047-81.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Severe acute hepatitis
- Cholestasis
- Hemolysis
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Guidelines
- Management of adult acute and acute-on-chronic liver failure in the ICU (part II)
- Management of hepatic encephalopathy
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Patient information
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Hepatitis C: what is it?
More Patient information
Videos
Tracheal intubation: animated demonstration
Bag-valve-mask ventilation: animated demonstration
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Acute liver failure

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

all patients

Contributors

Authors

Stevan A. Gonzalez, MD, MS

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Timothy J. Davern, MD

Disclosures

Muhammad Dawwas, MRCP

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice