Prediction of outcome and selection of the liver transplantat candidate in acute liver failure

Acute liver failure (ALF) is characterized by a sudden and severe deterioration of liver function, typically mirrored by a marked increase of the international normalized ratio (INR) and hepatic encephalopathy (HE). Due to various possible causes hepatocytes get damaged via either apoptotic or necrotic pathways. Anticipating the natural prognosis of a patient with ALF is one of the most challenging tasks in hepatology critical care. Important factors that influence the chance of spontaneous recovery are the underlying etiology of acute liver failure, the acuity of disease, and the severity of HE. Once an estimation of the prognosis in the individual patient has been made, this quickly has to be integrated in the discussion whether high-urgency liver transplantation is necessary and justifiable. This decision has to cover several medical, social, and organizational issues. Well organized liver transplantation programs around the world have achieved an impressive improvement of the 1 year survival rate in ALF from around 40% without transplantation up to nearly 80% with transplantation. The recent debate on whether severe acute alcoholic hepatitis could represent a new candidate eligible for high-urgency liver transplantation shows that the topic is still open for discussion.