Acute Liver Failure

Publication Date: June 27, 2023
Last Updated: June 29, 2023

Summary of Recommendations

In patients with ALF and grade 2 or higher encephalopathy, we suggest early CRRT for the management of hyperammonemia even in the absence of conventional RRT indications. (C, VL)

In patients with ALF, in the absence of active bleeding or impending high-risk procedure, we recommend against routine correction of coagulopathy. (C, VL)

In patients with ALF, we recommend against the routine use of prophylactic antimicrobial agents, given no improvement in either the rate of bloodstream infection or 21-day mortality. (C, L)

In patients with ALF, we recommend norepinephrine as the first-line vasopressor for hypotension refractory to fluid resuscitation. (S, M)

In patients with ALF with hypotension not responsive to norepinephrine, we suggest adding vasopressin as a secondary agent. (C, L)

In patients with suspected APAP toxicity, we recommend early administration of NAC. (S, L)

In patients with non-APAP ALF, we suggest the initiation of IV NAC. (S, M)

In patients with ALF due to reactivation of HBV, we recommend starting antiviral therapy with entecavir-based or tenofovir-based regimen. (S, L)

In patients with ALF due to mushroom poisoning, we recommend initiation of IV silibinin as soon as possible. IV penicillin G may be used if IV silibinin is unavailable. (C, VL)

In patients with ALF, we recommend using either the KCC or MELD score for prognostication. Patients meeting the KCC criteria or presenting with MELD >25 are at high risk of poor outcomes. (C, L)

Recommendation Grading


  • ALF: Acute Liver Failure
  • CRRT: Continuous Renal Replacement Therapy
  • HBV: Hepatitis B Virus
  • NAC: N-acetylcysteine
  • RRT: Renal Replacement Therapy


The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.



Acute Liver Failure

Authoring Organization

Publication Month/Year

June 27, 2023

Last Updated Month/Year

August 8, 2023

Supplemental Implementation Tools

Document Type


Country of Publication


Document Objectives

Acute liver failure (ALF) is a rare, acute, potentially reversible condition resulting in severe liver impairment and rapid clinical deterioration in patients without preexisting liver disease. Due to the rarity of this condition, published studies are limited by the use of retrospective or prospective cohorts and lack of randomized controlled trials. Current guidelines represent the suggested approach to the identification, treatment, and management of ALF and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence was reviewed using the Grading of Recommendations, Assessment, Development and Evaluation process to develop recommendations. When no robust evidence was available, expert opinions were summarized using Key Concepts. Considering the variety of clinical presentations of ALF, individualization of care should be applied in specific clinical scenarios.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Emergency care, Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Treatment, Management

Diseases/Conditions (MeSH)

D017114 - Liver Failure, Acute, D017093 - Liver Failure, D006501 - Hepatic Encephalopathy, D065290 - Acute-On-Chronic Liver Failure


acute liver failure, ALF, hepatic encephalopathy, liver failure, acute on chronic liver failure

Source Citation

Shingina, Alexandra MD, MSc1; Mukhtar, Nizar MD2; Wakim-Fleming, Jamilé MD, FACG3; Alqahtani, Saleh MBChB, MS4,5; Wong, Robert J. MD, MS, FACG6; Limketkai, Berkeley N. MD, PhD, FACG7; Larson, Anne M. MD8; Grant, Lafaine MD9. Acute Liver Failure Guidelines. The American Journal of Gastroenterology 118(7):p 1128-1153, July 2023. | DOI: 10.14309/ajg.0000000000002340

Supplemental Methodology Resources

Data Supplement