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Acute Liver Failure

Also known as: fulminant hepatic failure · ALF

Rapid loss of liver function with coagulopathy (raised INR) and hepatic encephalopathy in someone WITHOUT pre-existing chronic liver disease. It is multi-organ and high-mortality; some need transplantation.

Source · Reviewed 2026-08-15 · v1.0— AI-assisted draft — verify against the cited guideline before clinical use.

⚕️ Education only — not medical advice. Verify against the latest official guideline and your local protocol; confirm every drug dose against the cited source before clinical use.

Who gets it

Paracetamol overdose (a leading cause), viral hepatitis (A/E/B), drugs/toxins, pregnancy-related disease (acute fatty liver, HELLP), ischaemia, Wilson's and autoimmune hepatitis.

Red flags — escalate / refer

Worsening encephalopathy (cerebral-oedema risk), coagulopathy/bleeding, hypoglycaemia, renal failure, acidosis, or meeting transplant criteria → transfer to a liver/transplant unit.

Work-up / diagnosis

1INR/coagulation, LFTs, glucose, U&E, arterial gas/lactate, and a cause work-up (paracetamol level, viral serology, autoimmune screen, Wilson's, imaging).
2Grade the encephalopathy and identify the aetiology (it guides specific treatment).

Management — overview

Treat the cause — N-acetylcysteine for paracetamol (and it may help non-paracetamol ALF too).
Intensive supportive care: maintain glucose, careful fluids, treat infection, and correct coagulopathy only if bleeding or before a procedure.
Manage raised intracranial pressure/cerebral oedema.
Discuss early with a transplant centre using prognostic criteria (e.g., King's College).

In-depthFull dosing & advanced protocol

Drug dosing

N-acetylcysteine

Paracetamol ALF (considered in non-paracetamol ALF)

Adult dose: IV per protocol
Route: Intravenous

ICMRStandard Treatment Workflows (STWs), India — Dept. of Health Research & ICMR (2022+) ↗

Supportive (glucose, etc.)

Hypoglycaemia and organ support

Adult dose: Per protocol
Route: IV

WHOWHO Model List of Essential Medicines (electronic EML) (2025 (24th)) ↗

Coagulopathy + encephalopathy, no chronic liver disease

Give N-acetylcysteine early; it benefits paracetamol ALF and may help other causes.
Don't 'correct' the INR without bleeding — it is a key prognostic marker.
Transfer early per King's College criteria; watch for cerebral oedema in high-grade encephalopathy.

ICMRStandard Treatment Workflows (STWs), India — Dept. of Health Research & ICMR (2022+) ↗

References

Guidelines change. If something here is out of date, tell us — we keep these current.

🚩 Report outdated / suggest update

More protocols

HypertensionPersistently raised arterial pressure (≥140/90 mmHg) — a leading, modifiable cause of stroke, heart attack, heart failure and kidney disease.DengueAn Aedes-borne viral febrile illness. Most cases self-limit, but plasma leakage can cause severe dengue — early recognition of warning signs and careful fluid therapy save lives.MalariaA mosquito-borne protozoal (Plasmodium) febrile illness. In India P. vivax and P. falciparum predominate; prompt diagnosis and species-specific treatment prevent severe disease.

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👤 Who gets it

🚩 Red flags — escalate / refer

🔎 Work-up / diagnosis

🧭 Management — overview

💊 Drug dosing

N-acetylcysteine

Supportive (glucose, etc.)

📈 Coagulopathy + encephalopathy, no chronic liver disease

📚 References

More protocols

👤 Who gets it

🚩 Red flags — escalate / refer

🔎 Work-up / diagnosis

🧭 Management — overview

💊 Drug dosing

N-acetylcysteine

Supportive (glucose, etc.)

📈 Coagulopathy + encephalopathy, no chronic liver disease

📚 References

More protocols

Who gets it

Red flags — escalate / refer

Work-up / diagnosis

Management — overview

Drug dosing

Coagulopathy + encephalopathy, no chronic liver disease

References

Who gets it

Red flags — escalate / refer

Work-up / diagnosis

Management — overview

Drug dosing

Coagulopathy + encephalopathy, no chronic liver disease

References