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## Complete Summary

#### GUIDELINE TITLE

AASLD position paper: the management of acute liver failure.

#### BIBLIOGRAPHIC SOURCE(S)

Polson J, Lee WM. AASLD position paper: the management of acute liver
failure. Hepatology 2005 May;41(5):1179-97. \[179 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15841455)

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

On December 1, 2005, Novo Nordisk and the U.S. Food and Drug
Administration (FDA) notified healthcare professionals of revisions to
the WARNINGS and ADVERSE REACTIONS sections of the prescribing
information for NovoSeven, to provide updated safety information on
thrombotic and thromboembolic adverse events, based on clinical studies
in non-hemophilia patients and on post-marketing safety surveillance. A
clinical study in elderly, non-hemophiliac, intracerebral hemorrhage
patients indicated a potential increased risk of arterial thromboembolic
adverse events with use of NovoSeven, including myocardial ischemia,
myocardial infarction, cerebral ischemia and/or infarction. See the [FDA
Web
site](http://www.fda.gov/medwatch/safety/2005/safety05.htm#NovoSeven)
for more information.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Acute liver failure (ALF) due to:

-   Acetaminophen hepatotoxicity

-   Mushroom poisoning

-   Drug-induced hepatotoxicity

-   Viral hepatitis

-   Wilson disease

-   Autoimmune hepatitis

-   Acute fatty liver of pregnancy/hemolysis, elevated liver enzymes,
    low platelets (HELLP) syndrome

-   Acute ischemic injury

-   Budd-Chiari syndrome

-   Malignant infiltration

-   Indeterminate etiology

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Critical Care\
Emergency Medicine\
Gastroenterology\
Internal Medicine

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide a data-supported approach to the diagnostic, therapeutic and
preventive aspects of acute liver failure (ALF) care

#### TARGET POPULATION

Patients with acute liver failure (ALF)

#### INTERVENTIONS AND PRACTICES CONSIDERED

**[Diagnosis/Evaluation/Monitoring]{.underline}**

1.  Patient history, including exposure to viral infection and drugs and
    other toxins

2.  Physical examination, including evaluation of signs and symptoms;
    assessment and documentation of mental status; search for signs of
    chronic liver disease, jaundice, and right upper quadrant
    tenderness; palpation of liver

3.  Initial laboratory examinations

    -   Coagulation parameters

    -   Routine chemistries, including glucose

    -   Arterial blood gas measurements

    -   Complete blood counts and blood typing

    -   Acetaminophen level and screens for other drugs and toxins

    -   Viral hepatitis serologies

    -   Tests for Wilson disease

    -   Autoantibodies

    -   Pregnancy test

    -   Plasma ammonia

    -   Imaging and liver biopsy, if indicated

4.  Determination of etiology of liver failure

5.  Admission to intensive care unit (ICU), transfer to transplant
    facility, and placement on transplant list, as indicated

6.  Consultation with transplant center

7.  Monitoring of intracranial pressure and evaluation for signs of
    intracranial hypertension, as indicated

8.  Periodic surveillance cultures, to detect bacterial and fungal
    infections

9.  Monitoring of nutritional status (glucose, phosphate, potassium, and
    magnesium)

**[Management/Treatment]{.underline}**

**Etiologies**

*Acetaminophen Hepatotoxicity*

1.  Activated charcoal

2.  N-acetylcysteine (NAC)

*Mushroom Poisoning*

1.  Penicillin G

2.  Silymarin

3.  Placement on transplant list

*Drug-induced Hepatotoxicity*

1.  Discontinuation of all but essential medications

*Viral Hepatitis*

1.  Supportive care

2.  Nucleoside analogs (given before and after chemotherapy in patients
    with Hepatitis B surface antigen positivity)

3.  Acyclovir (for patients with herpes virus or varicella zoster)

*Wilson Disease*

1.  Immediate placement on transplant list

*Autoimmune Hepatitis*

1.  Corticosteroids (prednisone)

2.  Placement on transplant list

*Acute Fatty Liver of Pregnancy/Hemolysis, Elevated Liver Enzymes, Low
Platelets (HELLP) Syndrome*

1.  Consultation with obstetrician and expeditious delivery

*Acute Ischemic Injury*

1.  Cardiovascular support

*Budd-Chiari Syndrome*

1.  Liver transplantation

**Clinical Features**

*Encephalopathy*

1.  Lactulose

2.  Elevation of head and endotracheal intubation

3.  Phenytoin + low-dose benzodiazepines for seizures

4.  Mannitol with or without hyperventilation to reduce intracranial
    pressure

5.  Short-acting barbiturates

6.  Corticosteroids (considered, but not recommended)

*Infection*

1.  Prophylactic antibiotics and antifungals (may be considered, but
    have not been shown to improve overall outcomes)

*Coagulopathy*

1.  Replacement therapy (recommended only if hemorrhage is present or
    prior to invasive procedures)

*Gastrointestinal Bleeding*

1.  Prophylactic histamine-2 receptor (H2) blocking agents or
    proton-pump inhibitors

*Hemodynamics/Renal Failure*

1.  Fluid resuscitation and maintenance of adequate intramuscular volume

2.  Continuous mode dialysis support, as indicated

3.  Pulmonary artery catheterization

4.  Systemic vasopressor support (epinephrine, norepinephrine,
    dopamine), when necessary

*Metabolic Concerns*

1.  Maintenance of metabolic homeostasis

**Note**: Liver support systems were considered, but not recommended
outside of clinical trials.

#### MAJOR OUTCOMES CONSIDERED

-   Survival

-   Morbidity and mortality

-   Predictive value of tests

-   Effectiveness of treatment interventions

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

These recommendations provide a data-supported approach. They are based
on the following: (1) formal review and analysis of recently-published
world literature on the topic \[Medline search\], (2) American College
of Physicians Manual for Assessing Health Practices and Designing
Practice Guidelines, (3) guideline policies, including the American
Association for the Study of Liver Diseases (AASLD) Policy on the
Development and Use of Practice Guidelines and the American
Gastroenterological Association (AGA) Policy Statement on Guidelines,
(4) the experience of the authors in the specified topic.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Grade I**: Randomized controlled trials

**Grade II-1**: Controlled trials without randomization

**Grade II-2**: Cohort or case-control analytic studies

**Grade II-3**: Multiple time series, dramatic uncontrolled experiments

**Grade III**: Opinions of respected authorities, descriptive
epidemiology

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Evidence ratings (Grades I, II-1, II-2, II-3, and III) are defined at
the end of the \"Major Recommendations\" field.

**[Diagnosis and Initial Evaluation]{.underline}**

1.  Patients with acute liver failure (ALF) should be admitted and
    monitored frequently, preferably in an intensive care unit (ICU)
    (**Grade III**).

2.  Contact with a transplant center and plans to transfer appropriate
    patients with ALF should be initiated early in the evaluation
    process (**Grade III**).

3.  The precise etiology of ALF should be sought to guide further
    management decisions (**Grade III**).

**Table. Initial Laboratory Analysis**

-   Prothrombin time/international normalized ratio (INR)

-   Chemistries

    -   sodium, potassium, chloride, bicarbonate, calcium, magnesium,
        phosphate

    -   glucose

    -   aspartate aminotransferase (AST), alanine aminotransferase
        (ALT), alkaline phosphatase, gamma glutamyl transpeptidase
        (GGT), total bilirubin, albumin

    -   creatinine, blood urea nitrogen

-   Arterial blood gas

-   Arterial lactate

-   Complete blood count

-   Blood type and screen

-   Acetaminophen level

-   Toxicology screen

-   Viral hepatitis serologies

    -   anti-hepatitis A (HAV) IgM, hepatitis B surface antigen (HBSAg),
        anti-hepatitis B core antibody (anti-HBc IgM), antibody to
        hepatitis E (anti-HEV^\#^), and antibody to hepatitis C
        (anti-HCV\*)

-   Ceruloplasmin level\*\*

-   Pregnancy test (females)

-   Ammonia (arterial if possible)

-   Autoimmune markers

    -   antinuclear antibody (ANA), anti-smooth muscle antibody (ASMA),
        Immunoglobulin levels

-   Human immunodeficiency virus (HIV) status\*\*\*

-   Amylase and lipase

\* Done to recognize potential underlying infection\
\*\* Done only if Wilson disease is a consideration (e.g., in patients
less than 40 years without another obvious explanation for ALF); in this
case uric acid level and bilirubin to alkaline phosphatase ratio may be
helpful as well.\
\*\*\* Implications for potential liver transplantation\
\# If clinically indicated.

**[Determining Etiologies and Specific Therapies]{.underline}**

**Acetaminophen Hepatotoxicity**

4.  For patients with known or suspected acetaminophen overdose within 4
    hours of presentation, give activated charcoal just prior to
    starting N-acetylcysteine (NAC) (**Grade I**).

5.  Begin NAC promptly in all patients where the quantity of
    acetaminophen ingested, serum drug level, or rising
    aminotransferases indicate impending or evolving liver injury
    (**Grade II-1**).

6.  NAC may be used in cases of acute liver failure in which
    acetaminophen ingestion is possible or when knowledge of
    circumstances surrounding admission is inadequate (**Grade III**).

**Mushroom Poisoning**

7.  In ALF patients with known or suspected mushroom poisoning, consider
    administration of penicillin G and silymarin (**Grade III**).

8.  Patients with acute liver failure secondary to mushroom poisoning
    should be listed for transplantation, as this procedure is often the
    only lifesaving option (**Grade III**).

**Drug Induced Hepatotoxicity**

9.  Obtain details (including onset of ingestion, amount, and timing of
    last dose) concerning all prescription and non-prescription drugs,
    herbs and dietary supplements taken over the past year (**Grade
    III**).

10. Determine ingredients of non-prescription medications whenever
    possible (**Grade III**).

11. In the setting of acute liver failure due to possible drug
    hepatotoxicity, discontinue all but essential medications (**Grade
    III**) (See Table 3 \"Some Drugs Which May Cause Idiosyncratic Liver
    Injury to ALF\" in the original guideline.)

**Viral Hepatitis**

12. Viral hepatitis A- and B- (and E-) related acute liver failure must
    be treated with supportive care as no virus-specific treatment has
    been proven effective (**Grade III**).

13. Nucleoside analogs should be given prior to and continued for 6
    months after completion of chemotherapy in patients with Hepatitis B
    surface antigen positivity to prevent reactivation/acute flare of
    disease (**Grade III**).

14. Patients with known or suspected herpes virus or varicella zoster as
    the cause of acute liver failure should be treated with acyclovir
    (**Grade III**).

**Wilson Disease**

15. Diagnostic tests for Wilson disease should include ceruloplasmin,
    serum and urinary copper levels, total bilirubin/alkaline
    phosphatase ratio, slit lamp examination for Kayser-Fleischer rings,
    and hepatic copper levels when liver biopsy is feasible (**Grade
    III**).

16. Patients in whom Wilson disease is the likely cause of acute liver
    failure must be immediately placed on the liver transplant list
    (**Grade III**).

**Autoimmune Hepatitis**

17. When autoimmune hepatitis is suspected as the cause of acute liver
    failure, liver biopsy should be considered to establish this
    diagnosis (**Grade III**).

18. Patients with acute liver failure due to autoimmune hepatitis should
    be treated with corticosteroids (prednisone, 40-60 mg/day) (**Grade
    I**).

19. Patients should be placed on the list for transplantation even while
    corticosteroids are being administered (**Grade III**).

**Acute Fatty Liver of Pregnancy/Hemolysis, Elevated Liver Enzymes, Low
Platelets (HELLP) Syndrome**

20. For acute fatty liver of pregnancy or the HELLP syndrome,
    consultation with obstetrical services and expeditious delivery are
    recommended (**Grade III**).

**Acute Ischemic Injury**

21. In ALF patients with evidence of ischemic injury, cardiovascular
    support is the treatment of choice (**Grade III**).

**Budd-Chiari Syndrome**

22. Hepatic vein thrombosis with hepatic failure is an indication for
    liver transplantation, provided underlying malignancy is excluded
    (**Grade II-3**).

**Malignant Infiltration**

23. In patients with acute liver failure who have a previous cancer
    history or massive hepatomegaly, consider underlying malignancy and
    obtain imaging and liver biopsy to confirm or exclude the diagnosis
    (**Grade III**).

**Indeterminate Etiology**

24. If the etiological diagnosis remains elusive after extensive initial
    evaluation, liver biopsy may be appropriate to attempt to identify a
    specific etiology that might influence treatment strategy (**Grade
    III**).

**[Therapy: General Considerations]{.underline}**

**Central Nervous System and Intracranial Pressure Monitoring**

25. In early stages of encephalopathy, sedation should be avoided if
    possible. Lactulose may be used, but concern has been raised about
    increasing bowel distention during the subsequent transplant
    procedure (**Grades II-2, III**).

26. In patients progressing to grade III or IV encephalopathy, the head
    should be elevated to 30 degrees, and endotracheal intubation should
    be performed (**Grade III**).

27. Seizure activity should be treated with phenytoin and low-dose
    benzodiazepines (**Grade III**).

28. Although there is no consensus among the centers and experts,
    intracranial pressure (ICP) monitoring is mainly considered for
    patients who are listed for transplantation (**Grade III**).

29. In the absence of ICP monitoring, frequent evaluation for signs of
    intracranial hypertension are needed to identify early evidence of
    uncal herniation (**Grade III**).

30. In the event of intracranial hypertension, mannitol should be given
    and hyperventilation may be considered in order to temporarily
    reduce the ICP, but prophylactic use of these interventions is not
    helpful and therefore not recommended (**Grade I**).

31. Short-acting barbiturates may be considered for refractory
    intracranial hypertension (**Grade III**).

32. Corticosteroids should not be used to control elevated ICP in
    patients with acute liver failure (**Grade I**).

**Infection**

33. Periodic surveillance cultures should be performed to detect
    bacterial and fungal infections as early as possible and prompt
    treatment should be initiated accordingly (**Grades II-2, III**).

34. Prophylactic antibiotics and anti-fungals may be considered but have
    not been shown to improve overall outcomes (**Grades II-2, III**).

**Coagulopathy**

35. Replacement therapy for thrombocytopenia and/or prolonged
    prothrombin time is recommended only in the setting of hemorrhage or
    prior to invasive procedures (**Grade III**).

**Gastrointestinal (GI) Bleeding**

36. Patients with ALF in the intensive care unit should receive
    prophylaxis with H2 blocking agents or proton pump inhibitors (PPIs)
    (or sucralfate as a second-line agent) for acid-related
    gastrointestinal bleeding associated with stress (**Grades I,
    III**).

**Hemodynamics/Renal Failure**

37. Careful attention must be paid to fluid resuscitation and
    maintenance of adequate intravascular volume in patients with acute
    liver failure (**Grade III**).

38. If dialysis support is needed for acute renal failure, it is
    recommended that a continuous mode rather than an intermittent mode
    be used (**Grade I**).

39. Pulmonary artery catheterization should be considered in a
    hemodynamically unstable patient to ensure that appropriate volume
    replacement has occurred (**Grade III**).

40. Systemic vasopressor support with agents such as epinephrine,
    norepinephrine, or dopamine but not vasopressin should be used if
    fluid replacement fails to maintain mean arterial pressure (MAP) of
    50-60 mm Hg (**Grades III, II-1**).

**Metabolic Concerns**

41. Metabolic homeostasis must be carefully maintained in patients with
    acute liver failure. Overall nutritional status as well as glucose,
    phosphate, potassium and magnesium levels should be monitored
    frequently, with expeditious correction of derangements (**Grade
    III**).

**Table: Intensive Care of ALF**

+-----------------------------------------------------------------------+
| **Cerebral Edema/Intracranial Hypertension**                          |
+-----------------------------------------------------------------------+
| Grade I/II Encephalopathy                                             |
|                                                                       |
| -   Consider transfer to liver transplant facility and listing for    |
|     transplantation                                                   |
|                                                                       |
| -   Brain computed tomography (CT): rule out other causes of          |
|     decreased mental status; little utility to identify cerebral      |
|     edema                                                             |
|                                                                       |
| -   Avoid stimulation, avoid sedation if possible                     |
|                                                                       |
| -   Antibiotics: surveillance and treatment of infection required;    |
|     prophylaxis possibly helpful                                      |
|                                                                       |
| -   Lactulose: possibly helpful                                       |
|                                                                       |
| Grade III/IV Encephalopathy                                           |
|                                                                       |
| -   Continue management strategies listed above                       |
|                                                                       |
| -   Intubate trachea (may require sedation)                           |
|                                                                       |
| -   Elevate head of bed                                               |
|                                                                       |
| -   Consider placement of intracranial pressure (ICP) monitoring      |
|     device                                                            |
|                                                                       |
| -   Immediate treatment of seizures required; prophylaxis of unclear  |
|     value                                                             |
|                                                                       |
| -   Mannitol: use for severe elevation of intracranial pressure or    |
|     first clinical signs of herniation                                |
|                                                                       |
| -   Hyperventilation: effects short-lived; may use for impending      |
|     herniation                                                        |
+-----------------------------------------------------------------------+
| **Infection**                                                         |
+-----------------------------------------------------------------------+
| -   Surveillance for and prompt antimicrobial treatment of infection  |
|     required                                                          |
|                                                                       |
| -   Antibiotic prophylaxis possibly helpful but not proven            |
+-----------------------------------------------------------------------+
| **Coagulopathy**                                                      |
+-----------------------------------------------------------------------+
| -   Vitamin K: give at least one dose                                 |
|                                                                       |
| -   Fresh frozen plasma (FFP): give only for invasive procedures or   |
|     active bleeding                                                   |
|                                                                       |
| -   Platelets: give for platelet counts \<10,000/mm^3^ or invasive    |
|     procedures                                                        |
|                                                                       |
| -   Recombinant activated factor VII: possibly effective for invasive |
|     procedures                                                        |
|                                                                       |
| -   Prophylaxis for stress ulceration: give histamine-2 receptor      |
|     blocker or proton pump inhibitor                                  |
+-----------------------------------------------------------------------+
| **Hemodynamics/Renal Failure**                                        |
+-----------------------------------------------------------------------+
| -   Pulmonary artery catheterization                                  |
|                                                                       |
| -   Volume replacement                                                |
|                                                                       |
| -   Pressor support (dopamine, epinephrine, norepinephrine) as needed |
|     to maintain adequate mean arterial pressure                       |
|                                                                       |
| -   Avoid nephrotoxic agents                                          |
|                                                                       |
| -   Continuous modes of hemodialysis if needed                        |
|                                                                       |
| -   N-acetylcysteine, prostacyclin: effectiveness unknown             |
|                                                                       |
| -   Vasopressin: not helpful in ALF; potentially harmful              |
+-----------------------------------------------------------------------+
| **Metabolic Concerns**                                                |
+-----------------------------------------------------------------------+
| -   Follow closely: glucose, potassium, magnesium, phosphate          |
|                                                                       |
| -   Consider nutrition: enteral feedings if possible or total         |
|     parenteral nutrition                                              |
+-----------------------------------------------------------------------+

**[Transplantation and Prognosis]{.underline}**

**Transplantation**

42. Urgent hepatic transplantation is indicated in acute liver failure
    where prognostic indicators suggest a high likelihood of death
    (**Grade II-3**).

**Liver Support Systems**

43. Currently available liver support systems are not recommended
    outside of clinical trials; their future in the management of ALF
    remains unclear (**Grades I, II-1**).

**Prognosis**

44. Currently available prognostic scoring systems do not adequately
    predict outcome and determine candidacy for liver transplantation.
    Reliance entirely upon these guidelines is thus not recommended
    (**Grades II-2, II-3, III**).

**[Definitions]{.underline}**:

**Grade I**: Randomized controlled trials

**Grade II-1**: Controlled trials without randomization

**Grade II-2**: Cohort or case-control analytic studies

**Grade II-3**: Multiple time series, dramatic uncontrolled experiments

**Grade III**: Opinions of respected authorities, descriptive
epidemiology

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence is specifically stated for each recommendation (see
\"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate diagnosis, evaluation, and management of acute liver failure
(ALF)

#### POTENTIAL HARMS

Not stated

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Refractory intracranial hypertension (ICH) and/or decreased cerebral
perfusion pressure (CPP) is considered a contraindication to liver
transplantation in many centers.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Intended for use by physicians, the recommendations in this document
suggest preferred approaches to the diagnostic, therapeutic and
preventive aspects of care. They are intended to be flexible, in
contrast to standards of care, which are inflexible policies to be
followed in every case. Specific recommendations are based on relevant
published information. This document has been designated as a Position
Paper, since the topic contains more data based on expert opinion than
on randomized controlled trials and thus is not considered to have the
emphasis and certainty of a Practice Guideline. Nevertheless, it serves
an important purpose of facilitating proper and high level patient care
and the authors have characterized the quality of evidence supporting
each recommendation, in accordance with the Practice Guidelines
Committee of the American Association for the Study of Liver Diseases
(AASLD) recommendations used for full Practice Guidelines (See \"Rating
Scheme for the Strength of the Evidence\" field). These recommendations
are fully endorsed by the AASLD.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Polson J, Lee WM. AASLD position paper: the management of acute liver
failure. Hepatology 2005 May;41(5):1179-97. \[179 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15841455)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005 May

#### GUIDELINE DEVELOPER(S)

American Association for the Study of Liver Diseases - Private Nonprofit
Research Organization

#### SOURCE(S) OF FUNDING

American Association for the Study of Liver Diseases

#### GUIDELINE COMMITTEE

Practice Guidelines Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: Julie Polson; William M. Lee

*Committee Members*: K. Rajender Reddy, MD (Chair); Bruce R. Bacon, MD;
Henry C. Bodenheimer, MD; Andres Cardenas, MD, MMSc; Robert L.
Carithers, Jr., MD; Stanley M. Cohen, MD; Timothy J. Davern, MD; James
E. Everhart, MD; Thomas W. Faust, MD; Steven L. Flamm, MD; Gregory J.
Gores, MD; Elizabeth Hespenheide, MSN, ACNP;  Maureen M. Jonas, MD;
Michael R. Lucey, MD; David R. Nelson, MD; F. Fred Poordad, MD; Margaret
C. Shuhart, MD, MS; Brent A. Tetri, MD; Zobair M. Younossi, MD, MPH;
Nizar N. Zein, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

*Disclosure Statement*: The authors have no conflicts of interest to
disclose.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Association for the Study of Liver Diseases Web
site](https://www.aasld.org/eweb/docs/practiceguidelines/Acuteliverfailure.pdf).

Print copies: Available from the American Association for the Study of
Liver Diseases, 1729 King Street, Suite 200; Alexandria, VA 22314;
Phone: 703-299-9766; Web site: [www.aasld.org](http://www.aasld.org/);
e-mail: <aasld@aasld.org>.

#### AVAILABILITY OF COMPANION DOCUMENTS

This guideline is available as a Personal Digital Assistant (PDA)
download via the APPRISOR™ Document Viewer from
[www.apprisor.com](http://www.apprisor.com/).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on July 11, 2005. This summary was
updated by ECRI on December 7, 2005 following the U.S. Food and Drug
Administration (FDA) advisory on NovoSeven.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the American Association for the Study of Liver Diseases\' copyright
restrictions.

### DISCLAIMER

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Date Modified: 11/3/2008