The most widely accepted prognostic tool for patients who present with ALF. Although fulfilment of these criteria has a high specificity for mortality, the sensitivity and negative predictive value remain low. Therefore, not fulfilling the criteria does not ensure survival.
Prospective data from the US Acute Liver Failure Study Group revealed the King's College Criteria had an overall specificity of 85.7% but lower sensitivity of 48.3% in prediction of mortality in 838 patients with ALF. The specificity was increased to 92.4% in the 374 patients who presented with ALF secondary to paracetamol (acetaminophen) overdose.
ALF secondary to paracetamol overdose:
-pH <7>
-INR >6.5 (PT >100 seconds) and
-serum creatinine >300 micromol/L (>3.4 mg/dL) in patients with grade 3 or 4 hepatic encephalopathy.
-pH <7>
-INR >6.5 (PT >100 seconds) and
-serum creatinine >300 micromol/L (>3.4 mg/dL) in patients with grade 3 or 4 hepatic encephalopathy.
Non-paracetamol associated ALF:
INR > 6.5 (PT > 100 sec) or
any 3 of the following:
-age between 10-40 yrs,
-aetiology non-A, non-B hepatitis or idiosyncratic drug reaction,
-duration of juandice before hepatic enchephalopathy > 7days,
-INR >3.5 (PT >50),
-Serum bilirubin > 300 mmole/l
Early referral to a transplant center should be the standard of care.
ReplyDelete●Any patient with documented acute liver failure, decompensated cirrhosis, or hepatocellular carcinoma within defined criteria is a potential candidate for liver transplantation.
●Contraindications to transplant include cardiopulmonary disease that cannot be corrected and is a prohibitive risk for surgery, malignancy outside of the liver within five years of evaluation (not including superficial skin cancers) or not meeting oncologic criteria for cure, and active alcohol or drug use.
●The first step in deciding the timing of referral is to determine if there has been a complication of end-stage liver disease. This is followed by a determination of severity of illness using the MELD score (calculator 3 and calculator 4) and Child-Pugh score (calculator 1 and calculator 2).
●Any patient with one of the defined complications of end-stage liver disease (eg, ascites, variceal bleeding, encephalopathy, or hepatocellular carcinoma), a Child-Pugh score greater than 7, and/or a MELD score of 10 should be considered for referral to a transplant center.