Pôle des maladies de l’appareil digestif, service de d’hépatologie, hôpital Beaujon, 100, boulevard du Général-Leclerc, 92110 Clichy, France, Unité de réanimation hépatodigestive, Inserm U773 CRB-3, hôpital Beaujon, 92110 Clichy, France
Acute liver failure is an uncommon condition, which can be fatal within a few hours or a few days. The incidence of acute hepatitis B has decreased. In parallel, paracetamol overdose now represents the most frequent cause of acute liver failure, in France as well as in the United Kingdom and the United States. Despite improvements in diagnostic tests, about 15% of patients still have acute liver failure of unknown origin. Classically, brain edema was the main cause the death. In recent years, multi-organ failure has become the predominant cause of death. Due to technical complexity, among other reasons, bioartificial liver is not a realistic option in the short-term. Albumin dialysis improves hemodynamic status in the most severe cases. However, improvement of brain edema is uncertain. In addition, a recent controlled study failed to show a significant benefit in terms of access to transplantation and mortality. For the most severe cases, emergency liver transplantation remains the safest option. In patients meeting the criteria for emergency liver transplantation (Clichy and/or King’s College criteria), the results of transplantation are markedly better than those of medical management. However, lifelong immunosuppression is necessary. Auxiliary liver transplantation is an alternative option, consisting in transplanting a partial graft and preserving a part of the native liver. This technique offers the possibility of delayed regeneration of the native liver. If regeneration is sufficient, immunosuppression can be withdrawn. Due to refinements in surgical techniques and a better selection of candidates, the results of auxiliary transplantation have become comparable to those of conventional transplantation. In the long-term, immunosuppression can be withdrawn in most patients.