AJG-22-2447 1128..1153.pdf

Introduction:
Acute liver failure (ALF) is a life-threatening condition characterized by abnormal liver tests, coagulopathy (INR ≥ 1.5), and hepatic encephalopathy (HE) in patients without preexisting liver disease. It has diverse etiologies and clinical presentations affecting multiple organ systems. Early recognition and treatment initiation are crucial for patient survival.

Guideline Development:
- Led by the American College of Gastroenterology (ACG).
- Based on literature review, expert opinions, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process.
- Key concepts and recommendations structured in statements with associated quality of evidence ratings.

Definition and Presentation:
- ALF is rare but potentially reversible severe liver impairment with rapid clinical deterioration in patients without preexisting liver disease.
- Global definitions vary, but key features include abnormal liver tests, coagulopathy, and HE.

Key Recommendations:
1. Early Diagnosis: Recognize ALF early through thorough history, physical examination, and laboratory testing.
2. Systemic Management: Implement supportive care including continuous renal replacement therapy (CRRT) for hyperammonemia in patients with encephalopathy (grade 2 or higher).
3. Transplant Considerations: Evaluate eligibility for liver transplantation based on MELD-Na (Model for End-Stage Liver Disease-Sodium) score and clinical status.
4. Etiological Investigation: Perform comprehensive laboratory and imaging studies to identify the underlying etiology of ALF.
5. Multidisciplinary Approach: Involve a hepatologist, gastroenterologist, nephrologist, neurologist, and other specialists for optimal patient care.

Key Concept Statements (Not GRADE-assessed):
- ALF has various etiologies including drug-induced liver injury, viral hepatitis, autoimmune hepatitis, and ischemic liver injury.
- Neurological complications like hepatic encephalopathy are a significant aspect of ALF management.
- Liver transplantation remains the only cure for ALF but is subject to availability and patient eligibility.

Conclusion:
These guidelines provide a framework for the diagnosis and management of ALF, emphasizing early recognition, individualized care, and consideration for liver transplantation.