Acute liver failure (ALF) is a syndrome of diverse aetiology, including hepatic encephalopathy, renal, cardiac and pulmonary failures, which result in a rapid loss of hepatic function. The mechanisms of liver injury contributing to ALF can be summarized into two categories: direct damage and immune-mediated liver injury. This review summarizes current concepts of immune-mediated liver injury from both clinical studies and animal models. We highlight immune responses of ALF from the liver injury perspective, which combines a variety of molecular and cellular mechanisms, particularly, the contribution of cytokines and the innate immune system. Hepatic and circulating inflammatory cytokines play a significant role in the pathophysiology of ALF including hepatocyte necrosis, extrahepatic complications and hepatocyte regeneration. Overproduction of cytokines, if unchecked, is hazardous to the host and may cause severe outcomes. Measuring pro-inflammatory cytokines in ALF may be of value for predictors of outcome. Innate and adaptive immune systems both involved in ALF contribute to immune-mediated liver injury. The innate immune response is activated much more rapidly compared with adaptive immunity, particularly in acute liver injury where the host has little time to trigger an effective adaptive immune response. From this point of view, the innate immune system may make a more profound contribution than the adaptive immune system. Furthermore, immune responses crosstalk with other physiological or pathophysiological factors, for example, coagulation factors which in turn determine the outcome of ALF and these are discussed.Acute liver failure (ALF) is a syndrome of diverse aetiologies in which patients without liver disease recognized previously sustain a liver injury that results in a rapid loss of hepatic function. The period between the initial symptoms and the manifestations of hepatic encephalopathy is crucial for the prognosis of these patients. Therefore, several groups have included the time window between the appearance of symptoms and the onset of encephalopathy in their definitions. The most recent definition uses the term ALF as hyperacute, acute and subacute liver failure; fulminant or sub-fulminant liver failure. APASL consensus and Chinese consensus suggest that liver failure can develop as ALF (in the absence of any pre-existing liver disease), acuteon-chronic liver failure (ACLF) (an acute deterioration of known or unknown chronic liver disease) or a chronic decompensation of an end-stage liver disease (1, 2).The aetiology of ALF is the most important determinant of outcomes. Differences in aetiology, outcomes and management are well understood. In the East and the developing world, ALF is mainly because of viral infections, primarily hepatitis B, but also A and especially in developing countries, E, as well as other non-hepatotropic viruses. In principle, four different mechanisms are primarily responsible: infectious (mainly viral), drugs/ toxins/chemicals, cardiovascular and metabolic (3...