Acute liver failure (ALF) is characterized by a sudden and rapid decline in liver function, presenting with jaundice, coagulopathy, and hepatic encephalopathy (HE). The interval between the onset of jaundice and encephalopathy is used to classify ALF into hyperacute, acute, and subacute types, which also helps in predicting clinical outcomes. There is notable geographic variation in the causes of ALF. In Western countries, paracetamol toxicity is the leading etiology, while in Asian countries, viral hepatitis is more common. In India, hepatitis A is the most frequent cause of ALF, while yellow phosphorus (YP) poisoning is frequently reported in the southern regions of the country. Outcomes in ALF have improved markedly over the past three decades, primarily due to advancements in critical care, a better understanding of disease mechanisms, and the timely use of organ support therapies. Consequently, many ALF patients, particularly those with hyperacute presentations, recover with medical management alone. However, patients with seronegative hepatitis, non-paracetamol drug-induced liver injury (DILI), or subacute ALF are more likely to require liver transplantation (LT). Management of ALF should take place at tertiary care centers with liver transplant capability. While emergency liver transplantation (LT) can be life-saving, determining the right candidates for LT remains challenging. Multiple prognostic scoring systems have been developed to assess mortality risk in the absence of LT. Among these, King’s College Hospital (KCH) criteria are the most extensively studied and widely used. However, due to its limited sensitivity, some patients who could benefit from LT may not meet its thresholds. The ALFED score, being dynamic, has shown better predictive accuracy but requires further validation. A significant barrier to emergency LT in ALF patients in Asian populations is the limited availability of deceased donor organs, especially for those listed under “supra-urgent” categories. In response, countries like India have advanced the use of living donor liver transplantation (LDLT). Additionally, auxiliary partial orthotopic liver transplantation (APOLT) is a specialized surgical approach used in selected ALF cases. This technique supports native liver regeneration, potentially eliminating the need for lifelong immunosuppression. Survival rates following LT in ALF have greatly improved, with current 1-year and 5-year survival rates around 80% and 70%, respectively—markedly better than in previous decades.