Management of the patient with decompensated liver disease is clearly more straightforward in specialist centres with multi-disciplinary input, access to liver transplantation teams and advanced technology. Bioartificial extra-corporeal liver support systems are undergoing evaluation and include the extra-corporeal liver assist device (ELAD developed by Vital Technologies). ELAD is an investigational, extra-corporeal, human cell-based system. The human liver-derived cells (VTL C3A) may mimic certain functions of in vivo human liver cells. The principles of operation of the ELAD system are as follows: plasma ultrafiltrate is passed through hollow fibre cartridges containing human liver-derived cells (VTL C3A cells) and allowing two-way transfer of toxins, metabolites and nutrients, mimicking liver function. Toxins, such as bilirubin, glucose and oxygen pass from the ultrafiltrate to the VTL C3A cells. Treated plasma ultrafiltrate is then reconstituted with blood cells and returned to the patient. Data evaluating this system shows trends indicating a potential for ELAD to increase survival rates in selected patients with decompensated liver failure. Issues in the management of liver failure include cardiorespiratory support, and the management of cerebral oedema. The principles for haemodynamic support are as for most critically ill patients, with early restoration of organ perfusion and use of vasopressors if hypotension persists despite restoration of volume. For the patient with liver failure, lactate-containing solutions and fluid overload should be avoided. New monitoring techniques for encephalopathy have been developed, including brain tissue oxygen tension, continuous EEG, transcranial Doppler and cerebral microdialysis. Key issues for regional centres are basic management principles, liaison with specialist centres and timing of transfer. Who and when to refer is a difficult problem for the regional Australasian unit, given the tyranny of distance and issues relating to retrieval and transfer of the critically ill patient. Early liaison with the regional liver unit is key.