Box 1.

Initial investigations for patients presenting with ALF. Adapted with permission.9

> Arterial blood gases: include lactate and arterial ammonia
> Haematology: full blood count and coagulation studies (INR and prothrombin time, fibrinogen); blood group
> Biochemistry: liver function tests (AST, ALT, ALP, GGT, bilirubin, albumin), renal function and electrolytes (Na, K, urea, creatinine, Mg, PO4), glucose, amylase, thyroid function tests, creatine kinase and lipids
> Hepatitis serology and viral screen: anti-HAV IgM, HBsAg, anti-HB core IgM and anti-HEV IgM, EBV, CMV, HSV, HIV, adenovirus and parvovirus
> Autoantibodies: antinuclear, anti-smooth muscle actin, anti-liver/kidney microsomal antibodies and immunoglobulins
> Toxicology screen: paracetamol and salicylate levels
> Metabolic screen: serum copper and caeruloplasmin
> Liver ultrasound: include assessment of patency of hepatic and portal veins and hepatic artery
  • ALF = acute liver failure; ALP = alkaline phosphatase; ALT = alanine transaminase; AST = aspartate aminotransferase; CMV = cytomegalovirus; EBV = Epstein–Barr virus; GGT = gamma-glutamyl transferase; HAV = hepatitis A virus; HB = hepatitis B; HEV = hepatitis E virus; HIV = human immunodeficiency virus; HSV = herpes simplex virus; IgM = immunoglobulin M; INR = international normalised ratio; K = potassium; Mg = magnesium;

  • Na = sodium; PO4 = phosphate.