Acute Liver Failure / Decompensated Liver Disease

Acute liver failure (ALF) = coagulopathy (INR >1.5) + encephalopathy in the absence of pre-existing liver disease. Decompensated chronic liver disease presents with jaundice, ascites, variceal bleeding, or encephalopathy. Both require urgent…

King's College Criteria / ALF Pathway

The pathway

1 · Identify the cause

Paracetamol overdose (most common in UK): check levels + time of ingestion
Viral hepatitis (A, B, E)
Autoimmune
Drug-induced (DILI)
Wilson's disease (young patient)
Decompensated CLD: alcohol, infection (SBP), variceal bleed

2 · Paracetamol overdose (most common ALF)

N-acetylcysteine (NAC) immediately if ANY doubt — even after 24h. Don't wait for levels. Refer to hepatology/transplant centre if INR rising, encephalopathy, or AKI.

3 · King's College Criteria (transplant referral)

Paracetamol: pH <7.3 OR INR >6.5 + Cr >300 + grade 3–4 encephalopathy
Non-paracetamol: INR >6.5 OR any 3 of: age <10 or >40, non-A non-B hepatitis/DILI, jaundice >7 days before encephalopathy, INR >3.5, bilirubin >300
Refer transplant centre if criteria met

4 · Hepatic encephalopathy

Grade 1–2: lactulose 30ml TDS (target 2–3 soft stools/day). Rifaximin 550mg BD (if recurrent). Avoid sedatives
Grade 3–4: ITU, airway protection, ammonia monitoring

5 · Spontaneous bacterial peritonitis (SBP)

Diagnostic paracentesis: neutrophils >250/mm³ = SBP. Treat with cefotaxime 2g IV TDS
Albumin 1.5g/kg on day 1, 1g/kg on day 3 (reduces hepatorenal syndrome risk)

6 · Coagulopathy

Do NOT correct INR with FFP unless actively bleeding (falsely reassures assessment and depletes volume). Vitamin K 10mg IV if nutritionally deficient. For active bleeding: FFP, platelets, cryoprecipitate guided by TEG if available.

Drugs

Drug	Dose	Route	Notes
N-acetylcysteine (NAC)	150mg/kg over 1h, then 50mg/kg over 4h, then 100mg/kg over 16h	IV	Paracetamol OD. Start immediately. Continue even if levels below treatment line.
Lactulose	30ml TDS	PO/NG	Hepatic encephalopathy. Target 2–3 soft stools/day.
Cefotaxime	2g TDS	IV	SBP treatment. 5-day course.
Albumin	1.5g/kg	IV	Day 1 in SBP. Prevents hepatorenal syndrome.
Terlipressin	2mg QDS	IV	Hepatorenal syndrome type 1. With albumin. Stop if no response at 48h.

When to escalate

King's College Criteria met — immediate liver transplant centre referral,Grade 3–4 encephalopathy (confusion/coma) — ITU, intubation,Variceal haemorrhage — octreotide + endoscopy (see UGI bleed pathway),Hepatorenal syndrome — terlipressin + albumin; dialysis if refractory,AKI in ALF — nephrology + transplant hepatology

Reference: BSG ALF Guidelines 2017 / EASL Clinical Practice Guidelines: ALF 2017

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