Acute liver failure classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2] Aditya Govindavarjhulla, M.B.B.S. [3]


Acute liver failure may be classified on the basis of the time interval between the onset of symptoms and the development of encephalopathy as hyperacute, acute, subacute, fulminant, subfulminant and late-onset. The different classification systems used are O’Grady system, Bernuau system, and Japanese system. This classification based on time duration provides helpful clues about etiology, complications, and prognosis such as in hyperacute cases, the cause is usually viral infections or acetaminophen toxicity. The subacute cases can be due to idiosyncratic drug reactions and can also be confused with chronic liver disease. The hyperacute liver failure has a better prognosis than subacute liver failure.


Acute liver failure may be classified on the basis of the duration of the symptoms between the onset of jaundice to the onset of encephalopathy. The different classification systems based on the number of weeks from the appearance of jaundice to the encephalopathy are:[1][2][3][4][5][6]

Classification system Duration
O’Grady System
  • Hyperacute (0 - 1 week)
  • Acute ( From 2nd week - 4 weeks)
  • Subacute ( From 4th week - 12 weeks)
Bernuau System
  • Fulminant ( 0 - 2 weeks)
  • Subfulminant ( 2 weeks - 12 weeks)
Japanese System
  • Fulminant (0 - 8 weeks)
    • Acute ( 0 - 1.5 weeks)
    • Subacute ( 1.5 weeks - 8 weeks)
  • Late-Onset ( 8 weeks - 12 weeks)

Classification based on etiology

There is no established classification of acute liver failure on the basis of etiology. However, it can be classified on the basis of etiology as:[7][8]




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  1. O'Grady JG, Schalm SW, Williams R. Acute liver failure: redefining the syndromes. Lancet 1993;342:273-5. PMID 8101303.
  2. O'Grady JG (2005). "Acute liver failure". Postgraduate medical journal. 81 (953): 148–54. doi:10.1136/pgmj.2004.026005. PMID 15749789.
  3. Williams R (1996). "Classification, etiology, and considerations of outcome in acute liver failure". Semin Liver Dis. 16 (4): 343–8. doi:10.1055/s-2007-1007247. PMID 9027947.
  4. O'Grady JG, Schalm SW, Williams R (1993). "Acute liver failure: redefining the syndromes". Lancet. 342 (8866): 273–5. PMID 8101303.
  5. Bernuau J, Rueff B, Benhamou JP (1986). "Fulminant and subfulminant liver failure: definitions and causes". Semin Liver Dis. 6 (2): 97–106. doi:10.1055/s-2008-1040593. PMID 3529410.
  6. Mochida S, Nakayama N, Matsui A, Nagoshi S, Fujiwara K (2008). "Re-evaluation of the Guideline published by the Acute Liver Failure Study Group of Japan in 1996 to determine the indications of liver transplantation in patients with fulminant hepatitis". Hepatol Res. 38 (10): 970–9. doi:10.1111/j.1872-034X.2008.00368.x. PMID 18462374.
  7. Lee WM, Squires RH, Nyberg SL, Doo E, Hoofnagle JH (2008). "Acute liver failure: Summary of a workshop". Hepatology. 47 (4): 1401–15. doi:10.1002/hep.22177. PMC 3381946. PMID 18318440.
  8. Lee WM (2008). "Etiologies of acute liver failure". Semin. Liver Dis. 28 (2): 142–52. doi:10.1055/s-2008-1073114. PMID 18452114.

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