Over the past 8 years, an increasing frequency of acetaminophen overdose cases and a decreasing frequency of indeterminate and Hepatitis A virus (HAV) cases has been noted. A recent analysis of 1,033 consecutive adult patients enrolled through July 2007 demonstrates that acetaminophen overdose accounts for 46% of cases, followed by indeterminate ALF (15%), and idiosyncratic drug reactions (12%) ( Figure 1). The United States Acute Liver Failure Study Group (ALFSG) is a network of 23 tertiary care centers that have been prospectively studying the etiologies and outcomes of ALF since 1998. Therefore, early referral of patients with a poor prognosis to a liver transplant center is essential to optimize clinical outcomes.ĪPAP= Acetaminophen, HAV= Hepatitis A virus, HBV= Hepatitis B virus, ALF = acute liver failure, ALT = alanine aminotransferase (Data provided by William Lee, MD, and the US ALFSG, July 2007) Emergency liver transplantation is associated with a 70% 1-year patient survival, but less than 10% of ALF patients are listed and up to 20% of listed patients die awaiting liver transplantation. In addition, cerebral edema is notoriously difficult to diagnose and treat and can lead to irreversible brain ischemia and eventual death. Many ALF patients develop infectious, cardiopulmonary, or renal complications that can progress to multi-organ failure. Fortunately, most acetaminophen overdose patients recover with early N-acetylcysteine (NAC) therapy and supportive care, but regulatory actions are needed to prevent future cases. Acetaminophen overdose is the most common cause of ALF in Western countries and its incidence appears to be increasing. The etiology of ALF is usually rapidly established by patient history, laboratory tests, and imaging studies, but the etiology remains unknown in up to 20% of cases. Acute liver failure (ALF) is an uncommon, but dramatic, clinical syndrome defined by the onset of coagulopathy (INR > 1.5), and mental status changes within 8 to 26 weeks of presentation.
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