One of the most challenging problems in pediatric hepatology is the child who presents with acute liver failure (ALF). The barriers to determining a specific diagnosis are multiple and daunting. There is a very limited time frame for completing an evaluation before liver trans-plantation. Many diagnostic tests for specific causes do not have high sensitivity or specificity and are not standardized across institutions that care for these patients. Liver biopsy is often not possible because of coagulopathy, and transjugular biopsy is often insufficient for a diagnosis. Even adequate tissue sampling often does not yield a specific diagnosis, especially in the presence of massive necrosis and parenchymal collapse. Finally, even after an exhaustive workup is completed, there will still be a significant proportion of cases with an "indeterminate" diagnosis. Currently, no specific cause is defined in approximately half of pediatric patients with ALF.
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