Sudden and rapid deterioration of hepatic function leading to jaundice, coagulopathy and encephalopathy defines acute liver failure (ALF). Timing of jaundice to encephalopathy classifies ALF into hyperacute, acute and sub-acute liver failure and prognosticates outcome. There exists a significant geographical heterogeneity in the etiology of ALF
paracetamol toxicity is the most common cause in the west, whereas viral hepatitis predominates Asian countries. Hepatitis A is the leading cause for ALF in India. ALF due to yellow phosphorus poisoning is observed commonly in southern India. Clinical outcomes of ALF have improved significantly over the last theee decades and attributed improvement in critical care services, better understanding of the disease and timely initiation of appropriate organ support. Thus, a majority of patients with ALF recover with medical management, in particular hyperacute liver failure. However, patients with seronegative hepatitis, non-paracetamol drug toxicity and sub-acute liver failure are more likely to require liver transplantation (LT). Patients with ALF should be managed in a higher centre with transplant set-up. Emergency LT is a life-saving procedure in ALF, but selection of patients for LT may be a challenge. Various prognostic models have been evaluated to identify those with increased chance of death in the absence of LT. King's College criteria is an extensively studied prognostic model, time tested and used widely across several centres, but has a lower sensitivity missing out on some patients who may benefit from LT. ALF-Early Dynamic (ALFED) being a dynamic model may have better predictability but needs more validation. Timely availability of cadaver organ in ALF patients waitlisted for 'supra-urgent' LT may be an issue. Lower organ donation rates in India and other Asian countries have innovated living donor liver transplantation. Auxiliary partial orthotopic liver transplantation (APOLT) is an exclusive surgical technique in selected patients with ALF allowing regeneration of native liver eliminating the need for long-term immunosuppression. One and five-year survival following LT in ALF patients is around 80% and 70%, respectively, and has significantly improved compared to previous era.