Acute liver failure (ALF), a liver injury developing over 26 weeks or less with evidence of coagulopathy and encephalopathy, disproportionately affects young, healthy adults with high resultant mortality.[1] ALF results in cerebral dysfunction, which can range from minor encephalopathy to coma, and is associated with high neurological morbidity due to higher grade hepatic encephalopathy (HE), cerebral edema, and elevated intracranial pressure (ICP),[2,3] although other complications including seizures may contribute.[4]

While ALF is considered a rare syndrome, with an estimated annual incidence of 1–5 cases per million people yearly,[5] there appears to be a trend toward increasing numbers of hospitalizations for ALF, including up to a 30% increase in the United States over a 4-year period.[6] Etiologies of ALF vary geographically; in developed countries, the majority of cases are caused by toxic ingestions, autoimmune hepatitis, or hepatitis B, while cases in developing countries most commonly are caused by hepatitis A, B, or E.[7] ALF etiologies appear in Table 11.1.