GASTROINTESTINAL SYSTEM: Edited by Constantine J. KarvellasUpdate on the management of acute liver failureTrovato, Francesca M.; Rabinowich, Liane; McPhail, Mark J.W.Author Information Liver Intensive Therapy Unit, Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK Correspondence to Mark J.W. McPhail, Senior Lecturer & Honorary Consultant in Liver Critical Care & Hepatology, Institute of Liver Studies, 3rd floor Cheyne Wing, Kings College Hospital, Denmark Hill, London SE5 9RS, UK. E-mail: firstname.lastname@example.org Current Opinion in Critical Care: April 2019 - Volume 25 - Issue 2 - p 157-164 doi: 10.1097/MCC.0000000000000583 Buy Metrics Abstract Purpose of review This review describes the current intensive care management of acute liver failure (ALF) and the latest evidence for emerging therapies. Recent findings Mortality from ALF continues to improve and in some cases, medical therapy can negate the need for liver transplantation because of protocolized management in specialist centres. Liver transplantation remains the cornerstone of management for poor prognosis ALF. The reduced use of blood products in ALF reflects growing evidence of balanced haemostasis in severe liver disease. Prophylactic therapeutic hypothermia is no longer recommended for neuroprotection. In cases not suitable for liver transplantation, high-volume plasma exchange (HVP) has potential benefit, although further research on the optimal timing and dosing is needed. Although sepsis remains an important complication in ALF, the use of prophylactic antimicrobials is being questioned in the era of emerging bacterial resistance. Summary ICU management of ALF has improved such that liver transplantation is not required in some cases. HVP has emerged as a potential therapy for patients who may not be good liver transplantation candidates. Nevertheless in suitable patients with poor prognosis liver transplantation remains the optimal therapy. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.