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Clinical Guideline for Diagnosis and Management of Acute Liver Failure

The American College of Gastroenterology (ACG) has developed a comprehensive clinical guideline for the diagnosis and management of acute liver failure (ALF). ALF is a life-threatening condition characterized by liver injury, coagulopathy, and hepatic encephalopathy. The guideline provides recommendations for specific etiologies and disease presentations, with a focus on early recognition and timely treatment. The guideline highlights several key recommendations. For patients with encephalopathy (≥ grade 2), early continuous renal replacement therapy is suggested to manage hyperammonemia. Antiviral therapy should be administered in cases of ALF due to hepatitis B virus reactivation. The King’s College Criteria or Model for End-Stage Liver Disease (MELD) score is recommended for prognostication of liver transplantation. The guideline also emphasizes the importance of individualized care based on specific clinical scenarios. It suggests early administration of N-acetylcysteine in cases of suspected N-acetyl-p-aminophenol (APAP) toxicity, while IV N-acetylcysteine initiation is suggested for non-APAP ALF. Routine correction of coagulopathy is not recommended unless there is active bleeding or a high-risk procedure. Prophylactic antimicrobial agents are not recommended as they have not shown improved outcomes. In cases of refractory hypotension, norepinephrine is recommended as the first-line vasopressor, with vasopressin as a secondary agent if needed. The guideline emphasizes the importance of differentiating ALF from acute-on-chronic liver failure and decompensated cirrhosis, as management approaches differ significantly. Timely transfer to a transplant center is crucial in managing ALF, as it carries high short-term mortality.

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