What are the King's College criteria for liver transplantation?

From the Guidelines

The King's College Criteria for liver transplantation in acute liver failure prioritize patients with severe liver dysfunction, coagulopathy, and multi-organ failure, and include specific criteria for paracetamol and non-paracetamol induced liver failure, as outlined in the British Society of Gastroenterology guidelines 1. The criteria for paracetamol-induced liver failure include a pH less than 7.30 or a prothrombin time greater than 100 seconds and serum creatinine greater than 300 μmol/l if in grade III or IV coma.

• Key factors in the King's College Criteria for non-paracetamol induced liver failure include:
  • Prothrombin time greater than 100 seconds
  • Any three of the following:
    • aetiology: non-A, non-B (indeterminate) hepatitis, halothane hepatitis, idiosyncratic drug reactions
    • age less than 10 or greater than 40 years
    • jaundice to encephalopathy interval greater than 7 days
    • prothrombin time greater than 50 seconds
    • serum bilirubin greater than 300 μmol/l These criteria help identify patients with a poor prognosis who would benefit from urgent liver transplantation, as they have a predicted mortality of greater than 80% without transplantation, as indicated by the guidelines 1. Patients with non-paracetamol acute and subacute liver failure, including fulminant Wilson’s disease, should be referred to a transplant centre, according to the guidelines 1.

From the Research

Kings College Criteria for Liver Transplant

The Kings College Criteria (KCC) are used to predict the mortality of patients with acute liver failure (ALF) and to identify those who require emergency liver transplantation 2, 3, 4, 5, 6.

• The KCC take into account various factors such as the etiology of ALF, the patient's age, the presence of hepatic encephalopathy, and the levels of certain laboratory tests like bilirubin and prothrombin time 2.
• Studies have shown that the KCC are comparable in overall accuracy to the Model for End-Stage Liver Disease (MELD) scores in predicting hospital mortality among patients with ALF 2.
• However, the KCC are more accurate in predicting hospital mortality among patients with acetaminophen-associated ALF, while MELD scores are more accurate in predicting mortality among patients with non-acetaminophen-associated ALF 2.
• The KCC have been shown to have a sensitivity of 58% and a specificity of 89% in identifying patients with acetaminophen-associated ALF who will die, while MELD scores have a sensitivity of 80% and a specificity of 53% 2.

Limitations and Controversies

• The KCC have been criticized for their limited sensitivity and specificity, and for not being optimal for all patients with ALF 2, 6.
• Some studies have suggested that the KCC may not be accurate in predicting mortality among patients with certain etiologies of ALF, such as hepatitis B or Wilson's disease 3, 5.
• There is ongoing debate about the use of the KCC versus other scoring systems, such as the MELD score, in predicting mortality among patients with ALF 2, 4, 6.

Clinical Applications

• The KCC are widely used in clinical practice to identify patients with ALF who require emergency liver transplantation 3, 6.
• The KCC can help clinicians to make decisions about the timing and necessity of liver transplantation, and to prioritize patients for transplantation 2, 3.
• However, the KCC should be used in conjunction with other clinical factors and scoring systems to ensure that patients receive the most appropriate treatment 2, 4, 6.