Observational Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 7, 2016; 22(33): 7595-7603
Published online Sep 7, 2016. doi: 10.3748/wjg.v22.i33.7595
Clinical management of acute liver failure: Results of an international multi-center survey
Liane Rabinowich, Julia Wendon, William Bernal, Oren Shibolet
Liane Rabinowich, Oren Shibolet, Liver Unit, Department of Gastroenterology, Tel-Aviv Medical Center and Tel-Aviv University, Tel-Aviv 64239, Israel
Julia Wendon, William Bernal, Liver Intensive Therapy Unit, Institute of Liver Studies, King’s College Hospital, London SE5 9RS, United Kingdom
Author contributions: Wendon J and Bernal W contributed to study concept and design and acquisition of data; Rabinowich L, Wendon J, Bernal W and Shibolet O contributed to analysis and interpretation of data; Rabinowich L contributed to statistical analysis; Rabinowich L and Shibolet O contributed to drafting of the manuscript; Wendon J, Bernal W and Shibolet O contributed to critical revision of the manuscript; Bernal W and Shibolet O contributed equally.
Institutional review board statement: Non-identifiable data was gathered as part of the EuroALF registry. The study was performed with the approval of the local research ethics committee.
Informed consent statement: Survey - the participants are EUROALF members listed in appendix A. Informed consent waiver was obtained.
Conflict-of-interest statement: The authors declare no conflict of interest related to this publication.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at william.bernal@kcl.ac.uk.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: William Bernal, MD, FRCP, Liver Intensive Therapy Unit, Institute of Liver Studies, King’s College Hospital, Denmark Hill, London SE5 9RS, United Kingdom. william.bernal@kcl.ac.uk
Telephone: +44-203-2994458 Fax: +44-203-2993167
Received: January 6, 2016
Peer-review started: January 6, 2016
First decision: January 28, 2016
Revised: March 3, 2016
Accepted: March 30, 2016
Article in press: March 30, 2016
Published online: September 7, 2016

To assess the practice of caring for acute liver failure (ALF) patients in varying geographic locations and medical centers.


Members of the European Acute Liver Failure Consortium completed an 88-item questionnaire detailing management of ALF. Responses from 22 transplantation centers in 11 countries were analyzed, treating between 300 and 500 ALF cases and performing over 100 liver transplants (LT) for ALF annually. The questions pertained to details of the institution and their clinical activity, standards of care, referral and admission, ward- based care versus intensive care unit (ICU) as well as questions regarding liver transplantation - including criteria, limitations, and perceived performance. Clinical data was also collected from 13 centres over a 3 mo period.


The interval between referral and admission of ALF patients to specialized units was usually less than 24 h and once admitted, treatment was provided by a multidisciplinary team. Principles of care of patients with ALF were similar among centers, particularly in relation to recognition of severity and care of the more critically ill. Centers exhibited similarities in thresholds for ICU admission and management of severe hepatic encephalopathy. Over 80% of centers administered n-acetyl-cysteine to ICU patients for non-paracetamol-related ALF. There was significant divergence in the use of prophylactic antibiotics and anti-fungals, lactulose, nutritional support and imaging investigations in admitted patients and in the monitoring and treatment of intra-cranial pressure (ICP). ICP monitoring was employed in 12 centers, with the most common indications being papilledema and renal failure. Most patients listed for transplantation underwent surgery within an average waiting time of 1-2 d. Over a period of 3 mo clinical data from 85 ALF patients was collected. Overall patient survival at 90-d was 76%. Thirty six percent of patients underwent emergency LT, with a 90% post transplant survival to hospital discharge, 42% survived with medical management alone.


Alongside similarities in principles of care of ALF patients, major areas of divergence were present in key areas of diagnosis, monitoring, treatment and decision to transplant.

Keywords: Acute liver failure, Liver transplantation, Intra-cranial pressure, Hepatic encephalopathy

Core tip: Acute liver failure is rare, but carries high mortality and resource use. Standard of care and clinical practice varies between centers. In a survey conducted among members of the European-Acute-Liver-Failure consortium we have identified similarities in principles of care, including basic clinical management, recognition of severity and care of critically ill patients. Major areas of divergence were pre-intensive care unit (ICU) care and elements of ICU care. Further research is required regarding intra-cranial pressure monitoring and therapy, prophylactic antibiotics and anti-fungals, and liver support systems; we also identified a great need for improving prognostic evaluation for liver transplantation and refinement of transplantation criteria.