Acute liver failure and transplantation in children

Acute liver failure (ALF) was relatively easy to recognise in the days before liver transplantation became available as rescue therapy, because the diagnosis was based on end-stage disease manifestations such as profound coagulopathy, jaundice, encephalopathy and cerebral edema (in a patient with no history of chronic liver disease). These criteria no longer help us in an era when we struggle to define which patients are going to progress to this end-stage picture in the time necessary for evaluation and listing for life-saving transplantation. Ideally, identifying which patients will recover spontaneously or with appropriate treatment would relieve the justifiable concern that some patients receive a transplant when, given time, they would have recovered. Currently, the data to guide us in avoiding death without transplantation and unnecessary transplantation remain elusive.   This review will focus primarily on the aspects that surround the decision to undertake liver transplantation in a child with ALF. There are many excellent chapters and journal reviews which cover specific medical management of ALF and its complications; therefore this will not be addressed in this essay.