Key messages

• Acute hepatic failure is seen in patients with acute hepatic necrosis whose clinical course is complicated by the development of encephalopathy and coagulopathy.

• Metabolic derangements, including hypoglycemia, hypophosphatemia, and metabolic acidosis, are frequently seen.

• There is a high incidence of renal failure and hemodynamic disturbance, usually with a hypotensive, hyperdynamic state.

• Management is supportive in the first instance. Most patients are significantly volume depleted and require aggressive volume resuscitation.

• The level of consciousness can change rapidly. Patients who deteriorate to grade III coma should be electively ventilated because of the risk of cerebral edema and to allow optimal treatment.

• Consideration should always be given to liver transplantation; in selected patients the mortality with medical treatment alone remains at 90 per cent.

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