- Acute liver failure (ALF) is rare, but it is a significant clinical problem with high morbidity and mortality.
- It is characterized by rapid progression and death.
- Liver transplantation, the ultimate treatment strategy, is necessary for some patients and requires significant resources and a lifetime of immunosuppression, yet other patients have had spontaneous resolution and no long-term issues.
GRADE Strength of Recommendations and Implications
|Grade||Quality of Evidence|
|High||We are very confident that the true effect lies close to that of the estimate of the effect.|
|Moderate||We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.|
|Low||Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.|
|Very low||We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.|
|Grade||Strength of Recommendation|
|Strong||For the Patient||For the Clinician|
|Most individuals in this situation would want the recommended course of action and only a small proportion would not.|
|Conditional (weak)||The majority of individuals in this situation would want the suggested course of action, but many would not. Different choices will be appropriate for different patients.|
Summary of Recommendations of the AGA Clinical Guidelines for the Diagnosis and Management of Acute Liver Failure (ALF)
|Statement||Strength of Recommendation||Quality of Evidence|
|In patients presenting with ALF, the AGA suggests against routinely testing all patients for Wilson’s disease.|
Comments: In a setting of high clinical suspicion, testing for Wilson’s disease can be considered, keeping in mind the low positive predictive value. Although the management and outcome of ALF would not be altered, identiﬁcation of Wilson’s disease would allow appropriate post-transplantation management and screening of the patient’s family members.
|In patients presenting with ALF, the AGA suggests testing for herpes simplex virus (HSV) and treatment of patients with HSV.||Conditional||Very low|
|In immunocompetent patients presenting with ALF, the AGA suggests against routinely testing all patients for varicella zoster virus (VZV).||Conditional||Very low|
|In pregnant women presenting with ALF, the AGA suggests testing for hepatitis E.||Conditional||Very low|
|In patients presenting with ALF, the AGA suggests using the MELD score rather than the Kings College Criteria (KCC) as a prognostic scoring system.|
Comment: A Model for End-Stage Liver Disease (MELD) score of 30.5 (ﬁxed cut-off level) should be used for prognosis; higher scores predict the need for liver transplantation.
|In patients presenting with ALF, the AGA suggests against the routine use of liver biopsy.||Conditional||Very low|
|In patients presenting with ALF, the AGA suggests autoantibody testing for autoimmune hepatitis be performed.||Conditional||Very low|