361 Ch 360. Acute Liver Failure

Acute liver failure (ALF) = severe acute liver injury + encephalopathy + coagulopathy (INR ≥ 1.5) + no preexisting cirrhosis + duration < 26 weeks；etiology: acetaminophen (top US/UK), viral hepatitis (HAV, HBV; rare HCV, HEV in pregnancy), idiosyncratic DILI, autoimmune, Wilson, Budd-Chiari, ischemic, pregnancy (HELLP, AFLP), mushroom (Amanita), idiopathic (~ 15%)；Hyperacute (jaundice → encephalopathy < 7 days, often acetaminophen) — paradoxically better spontaneous survival vs subacute；presentation: HE (hepatic encephalopathy I-IV), jaundice, cerebral edema (life-threatening), coagulopathy, hypoglycemia, multi-organ failure, ↑ ICP；workup: acetaminophen level, viral hepatitis serologies, autoimmune markers (ANA, anti-SMA, IgG), ceruloplasmin (Wilson), pregnancy test, Doppler US (Budd-Chiari)；King’s College Criteria (acetaminophen and non-acetaminophen) for transplant decision；MELD ≥ 30 also indicator；management: ICU + airway protection (grade III-IV HE) + ICP management (head 30° + mannitol/hypertonic saline) + NAC for acetaminophen AND non-acetaminophen (NAC benefits early ALF) + nutrition + glucose monitoring + transplant evaluation；survival: with transplant 70-85% 1-yr; without ~ 40% overall (varies by etiology)。