title: Update in intensive care medicine: acute liver failure. Initial management, supportive treatment and who to transplant.
abstract: OBJECTIVE
  Acute liver failure (ALF) is associated with significant mortality. Although specific therapies may be available, the evidence base for these and for many aspects of supportive therapy has been slow to emerge. Liver transplantation continues to be a cornerstone of treatment, and the management of ALF, therefore, remains the domain of the specialist ICU. The purpose of this review is to identify and critically appraise the recent evidence and to inspire those who strive to provide excellent care for a difficult patient cohort.
  
  
  RESULTS
  Effective vaccination programmes have reduced the incidence of viral hepatitis in Europe and the USA. Spontaneous survival has improved in causes such as acetaminophen toxicity. Early recognition and proactive intensive management have reduced the incidence of early neurological death. The use of artificial liver assist devices and therapeutic plasma exchange is controversial, yet intriguing, with some early evidence of efficacy.
  
  
  CONCLUSIONS
  Increasingly sophisticated prognostication tools are evolving, which have the potential to transform clinical decision-making. A review of the indications for transplantation in acetaminophen toxicity is overdue. The use of therapeutic plasma exchange and extracorporeal liver support in ALF requires further investigation.
authors.affiliation: Liver Intensive Care Unit, King's College Hospital, London, UK.
authors.forename: Chris
authors.initials: C
authors.lastname: Willars
mesh_terms: D000082:Acetaminophen / Q000009:adverse effects; D000998:Antiviral Agents / Q000009:adverse effects; D056486:Chemical and Drug Induced Liver Injury / Q000209:etiology / Q000628:therapy*; D003422:Critical Care / Q000379:methods*; D005260:Female; D006525:Hepatitis, Viral, Human / Q000150:complications*; D006801:Humans; D017114:Liver Failure, Acute / Q000209:etiology / Q000401:mortality / Q000628:therapy* / Q000821:virology; D016031:Liver Transplantation / Q000379:methods*; D019164:Liver, Artificial / Q000639:trends; D008297:Male; D018579:Patient Selection; D010951:Plasma Exchange / Q000379:methods; D015995:Prevalence; D016896:Treatment Outcome
chemical_list: D000998:Antiviral Agents; D000082:Acetaminophen