Abstract Pediatric acute liver failure (PALF) is a life-threatening clinical syndrome associated with high morbidity and mortality, caused by multiple etiologies. Liver transplantation (LT) remains the definitive treatment for selected patients; however, advances in understanding the pathophysiology of PALF and improvements in critical care management have significantly enhanced native liver survival. Improved neurocritical care strategies have reduced cerebral edema as the leading cause of death. Extracorporeal therapies now serve as effective bridges to recovery or transplantation, in addition to optimized supportive care, reducing the need for LT to <20% of cases in many contemporary series.