This investigation summarizes and evaluates the results of a clinical protocol that we designed to care for patients with acute liver failure (ALF). Adult patients with ALF were enrolled in the protocol. Grade II portal-systemic encephalopathy prompted admission to the intensive care unit (ICU). Patients who met the clinical criterion were activated for liver transplantation. lntracranial pressure (ICP) was monitored in patients with grade 111 encephalopathy. An increase in ICP was treated with hyperventilation, diuretics, barbiturates, or a combination thereof. Survival was considered to have occurred if the patient left the hospital alive. Our series included 25 patients. Orthotopic liver transplantation (OLT) was performed on 19 patients, 12 of whom survived. Only 2 of 6 patients who did not undergo transplantation survived. Ten of 11 patients who underwent cute liver failure (ALF) is one of the most A catastrophic conditions in medicine. It is characterized by severe liver dysfunction, coagulopathy, hepatic encephalopathy, and cerebral edema in the absence of preexisting liver disease. Since it was first described, many nomenclatures have been used, which have included terms such as fulminant, subfulminant, and late-onset hepatic failure. A recently proposed terminology, based on a large series of patients seen over a period of 13 years at King's College Hospital, London4 divides the patients into three groups. Hyperacute liver failure is defined as the case whereby hepatic encephalopathy occurs within 7 days of the onset of jaundice. Hyperacute liver failure is associated with a high incidence of