• Stephen Warrillow, Heath Tibballs, Michael Bailey, Colin McArthur, Pia Lawson-Smith, Bheemasenachar Prasad, Matthew Anstey, Balasubramanian Venkatesh, Gemma Dashwood, James Walsham, Andrew Holt, Ubbo Wiersema, David Gattas, Matthew Zoeller, Mercedes Garcia Alvarez, Rinaldo Bellomo, and Australasian Management of Acute Liver Failure Investigators (AMALFI).
• Department of Intensive Care, Austin Health, Melbourne, VIC, Australia. Stephen.Warrillow@austin.org.au.
• Crit Care Resusc. 2019 Sep 1; 21 (3): 188-199.

ObjectiveAcute liver failure (ALF) leads to severe illness and usually requires admission to the intensive care unit (ICU). Despite its importance, little is known about patients with ALF in Australia and New Zealand.DesignBinational observational study to evaluate the aetiology, baseline characteristics, patterns of illness, management, and outcomes for patients with ALF admitted to Australian and New Zealand ICUs.SettingAll six Australian and New Zealand ICUs in liver transplant centres submitted de-identified data for ten or more consecutive patients with ALF. Data were obtained from the clinical record and included baseline characteristics, aetiology, mode of presentation, illness severity, markers of liver failure, critical care interventions, utilisation of transplantation, and hospital outcome.ResultsWe studied 62 patients with ALF. Paracetamol overdose (POD) was the underlying cause of ALF in 53% of patients (33/62), with staggered ingestion in 42% of patients (14/33). Among patients with POD, 70% (23/33) were young women, most had psychiatric diagnoses, and most presented relatively early with overt liver failure. This group were transplanted in only 6% of cases (2/33) and had an overall mortality of 24% (8/33). The remaining patients with ALF had less common conditions, such as hepatitis B and non-paracetamol drug-induced ALF. These patients presented later and exhibited less extreme evidence of acute hepatic necrosis. Transplantation was performed in 38% of patients (11/29) in this subgroup. The mortality of nontransplanted non-POD patients was 56% (10/18). Illness severity at ICU admission, initial requirement for organ support therapies and length of hospital stay were similar between patients with POD and non-POD ALF.ConclusionPOD is the major cause of ALF in Australian and New Zealand liver transplant centres and is a unique and separate form of ALF. It has a much lower associated mortality and treatment with liver transplantation than non-POD ALF. Non-POD patients have a poor prognosis in the absence of transplantation.

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