From the Guidelines
The King's College Criteria for liver transplantation in acute liver failure include specific parameters for paracetamol and non-paracetamol induced liver failure, such as pH, prothrombin time, serum creatinine, and encephalopathy grade, as outlined in the 1999 British Society of Gastroenterology guidelines 1. The criteria for paracetamol-induced liver failure are:
- pH < 7.30 (irrespective of grade of encephalopathy)
- Prothrombin time > 100 seconds and serum creatinine > 300 μmol/l if in grade III or IV coma. For non-paracetamol causes, the criteria include:
- Prothrombin time > 100 seconds (irrespective of grade of encephalopathy)
- Any three of the following:
- aetiology: non-A, non-B (indeterminate) hepatitis, halothane hepatitis, idiosyncratic drug reactions
- age < 10 or > 40 years
- jaundice to encephalopathy interval > 7 days
- prothrombin time > 50 seconds
- serum bilirubin > 300 μmol/l. These criteria have been supported by more recent studies, such as the 2020 Anaesthesia study, which highlights the importance of hepatic encephalopathy and other prognostic indicators in selecting candidates for liver transplantation 1. Key points to consider when applying the King's College Criteria include:
- The presence of encephalopathy, particularly grade 3-4, is a key indicator for liver transplantation
- Prothrombin time and serum creatinine levels are important markers of liver function and multi-organ involvement
- The criteria have a clinically acceptable specificity but limited sensitivity, highlighting the need for careful patient evaluation and consideration of alternative prognostic systems. Overall, the King's College Criteria remain a valuable tool for identifying patients with acute liver failure who may benefit from liver transplantation, and should be used in conjunction with clinical judgment and other prognostic indicators to optimize patient outcomes.
From the Research
Liver Failure Diagnosis Criteria Kings College
The King's College Criteria are a set of guidelines used to predict the outcome of patients with acute liver failure (ALF) and determine the need for liver transplantation. The criteria include factors such as:
- Prothrombin time
- Serum creatinine
- Grade of encephalopathy
- Presence of cerebral edema
- Acidosis
Studies on King's College Criteria
Several studies have evaluated the performance of the King's College Criteria in predicting outcome in patients with ALF. A meta-analysis of 18 studies found that the criteria had a sensitivity of 68% and a specificity of 82% in predicting survival in non-paracetamol-induced ALF 2. Another study found that the criteria performed best in patients with high-grade encephalopathy and in historically earlier studies, suggesting that modern medical management of ALF may modify the performance of the criteria 2.
Limitations of King's College Criteria
The King's College Criteria have been found to be insufficient for predicting the risk of mortality in certain contexts, such as yellow fever-induced ALF 3. In these cases, adaptations to the criteria may be necessary to ensure good applicability. Additionally, the criteria may not perform well in patients with low serum bilirubin levels or significant disparities between coagulation abnormalities and patient severity 3.
Other Prognostic Scoring Systems
Other prognostic scoring systems, such as the Model for End-stage Liver Disease (MELD) score, are also used to predict outcome in patients with ALF 4. These systems take into account factors such as liver function, renal function, and coagulation status to predict the risk of mortality.
Clinical Application
In clinical practice, the King's College Criteria are used in conjunction with other prognostic scoring systems and clinical judgment to determine the need for liver transplantation in patients with ALF. Patients who meet the criteria for liver transplantation are typically listed for transplantation and receive intensive care protocols to manage their condition until a transplant can be performed 4.