Episode two shifts from the drug to the failing organ, asking whether the liver can still recover on its own, how much time you have to decide, and when a different liver is the only answer. It anchors on the four-criterion definition of acute liver failure, then shows how etiology maps directly to the probability of spontaneous recovery. Two special causes, Wilsonian and herpes acute liver failure, each carry a distinctive fingerprint that demands empiric therapy before the workup completes. The King's College Criteria then triage who gets listed, with separate acetaminophen and non-acetaminophen paths calibrated to that recovery probability. Topics covered The four-criterion definition of acute liver failure Distinction from acute-on-chronic failure and cerebral edema Encephalopathy grading one through four Etiology distribution and its link to prognosis Non-cerebral and cerebral edema management Wilsonian acute liver failure and its fingerprint Herpes acute liver failure and empiric acyclovir N-acetylcysteine in non-acetaminophen failure King's College Criteria and transplant listing Key decisions Acute liver failure requires all four criteria: an INR of at least one and a half, hepatic encephalopathy of any grade, total illness duration under twenty-six weeks, and no pre-existing cirrhosis. Cerebral edema risk rises sharply at grade three or four encephalopathy, and arterial ammonia above roughly a hundred fifty to two hundred marks the threshold where herniation risk climbs, managed with head-of-bed elevation, hypertonic saline, mannitol, and continuous renal replacement. The Wilsonian fingerprint is Coombs-negative hemolysis with high indirect bilirubin, an alkaline-phosphatase-to-bilirubin ratio under four, an AST-to-ALT ratio over two, low uric acid, and Kayser-Fleischer rings, treated with urgent transplant and bridged by plasmapheresis while avoiding penicillamine. Herpes acute liver failure shows very high transaminases with a normal or low bilirubin, the anicteric pattern, so empiric intravenous acyclovir at five to ten milligrams per kilogram every eight hours is started in any pregnant or immunocompromised patient with indeterminate failure. N-acetylcysteine improves transplant-free survival in non-acetaminophen failure only with grade one or two encephalopathy, not grade three or four, so it is given empirically inside the early-grade window at the same dosing as for acetaminophen. The acetaminophen King's College path is met by an arterial pH under seven point three after resuscitation, or by grade three or four encephalopathy plus an INR over six and a half plus a creatinine over three point four. The non-acetaminophen path is met by an INR over six and a half alone, or by any three of five features: age under ten or over forty, indeterminate or drug-induced etiology, jaundice over seven days before encephalopathy, an INR over three and a half, and a bilirubin over seventeen and a half. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - Introduction: from the drug to the failing organ (00:46) - The four-criterion definition (02:22) - Acute-on-chronic distinction and grading (03:31) - Etiology distribution and prognosis (04:49) - Non-cerebral and cerebral edema management (06:49) - Wilsonian acute liver failure (09:25) - Herpes acute liver failure (11:05) - N-acetylcysteine in non-acetaminophen failure (12:09) - King's College Criteria and listing

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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