Acute Liver Failure — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] King's College criteria
   Etiology? Do King's College transplant criteria apply? (ALF = hepatic encephalopathy + coagulopathy (INR ≥1.5) within 26 weeks in someone without chronic liver disease. Etiologies: acetaminophen, viral hepatitis (HBV important in some regions), drugs, autoimmune, Wilson's, toxic mushrooms, etc. King's College criteria (predict poor prognosis/need for transplant) — acetaminophen: pH <7.30 (after resuscitation), or all of INR >6.5 + Cr >300 µmol/L + grade III–IV encephalopathy; non-acetaminophen: INR >6.5 alone, or any three of (age <10/>40, non-A non-B hepatitis/drug/Wilson etiology, jaundice-to-encephalopathy >7 days, INR >3.5, bilirubin >300 µmol/L).)
   • Meets King's College criteria / severe → Criteria met → early transfer to transplant center
   • Criteria not met / early → Early · support + NAC
2. [End] Early · support + NAC
   ICU monitoring, aggressive support — give N-acetylcysteine (NAC) if acetaminophen cannot be excluded (also beneficial early in non-acetaminophen ALF); monitor neuro/coagulation/glucose/electrolytes/blood gas; manage hypoglycemia, cerebral edema, infection (low threshold for antibiotics); do not give prophylactic FFP (unless active bleeding/before a procedure, and it confounds INR monitoring); reassess serially, transfer for transplant once criteria are met.
3. [End] Criteria met → early transfer to transplant center
   King's College criteria met / severe (poor prognosis): transfer early to a liver transplant center (time-critical). Continue NAC; intensive ICU support: cerebral edema/raised ICP (grade III–IV — head elevation, hypertonic saline/mannitol, avoid hypercapnia), frequent glucose checks to prevent hypoglycemia, AKI/renal replacement, broad-spectrum antimicrobials/antifungals (low threshold), correct electrolytes/metabolic derangements, circulatory support; transfuse FFP for coagulopathy only with active bleeding/before a procedure. Etiology-specific treatment (antivirals for HBV, penicillin/silibinin for toxic mushrooms, etc.).

Source guidelines & references

• King's College criteria (O'Grady 1989); BSG/AASLD acute liver failure

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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