From the Guidelines
The King's College Criteria for acute liver failure should be used to determine the need for liver transplantation, with 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 < 7.30 or a prothrombin time > 100 seconds and serum creatinine > 300 μmol/l if in grade III or IV coma. For non-paracetamol induced liver failure, the criteria include a prothrombin time > 100 seconds or any three of the following: aetiology of non-A, non-B hepatitis, halothane hepatitis, or idiosyncratic drug reactions, age < 10 or > 40 years, jaundice to encephalopathy interval > 7 days, prothrombin time > 50 seconds, or serum bilirubin > 300 μmol/l. Key points to consider when applying these criteria include:
- The presence of encephalopathy, which is a critical factor in determining the need for transplantation
- The severity of coagulopathy, as indicated by prothrombin time and serum creatinine levels
- The aetiology of liver failure, with certain causes such as non-A, non-B hepatitis and idiosyncratic drug reactions being associated with a higher risk of poor outcomes
- The patient's age, with those < 10 or > 40 years being at higher risk of poor outcomes. It is essential to refer patients with non-paracetamol acute and subacute liver failure, including fulminant Wilson's disease, to a transplant centre, as recommended by the guidelines 1.
From the Research
Kings Criteria for Acute Liver Failure
- The Kings College Criteria (KCC) are used to predict the outcome of patients with acute liver failure (ALF) and determine the need for liver transplantation 2, 3, 4.
- The KCC have a high specificity (83%) but low sensitivity (47%) in predicting mortality in patients with acetaminophen-induced ALF 2.
- A meta-analysis of 18 studies found that the KCC had a summary sensitivity of 68% and specificity of 82% in predicting survival in non-paracetamol-induced ALF 3.
- The KCC perform better in patients with high-grade encephalopathy and in historically earlier studies, suggesting that modern medical management of ALF may modify their performance 3.
Comparison with Model for End-Stage Liver Disease (MELD) Scores
- The MELD score and KCC are comparable in overall accuracy in predicting hospital mortality in patients with ALF 4.
- The KCC are more accurate in predicting hospital mortality in patients with acetaminophen-associated ALF, while MELD scores are more accurate in patients with non-acetaminophen-associated ALF 4.
- The KCC have a higher specificity than MELD scores in predicting hospital mortality in patients with ALF, which is important for decision-making regarding emergency liver transplantation 4.
Clinical Application
- The KCC are used in conjunction with other prognostic factors, such as the MELD score, to determine the need for liver transplantation in patients with ALF 5.
- Early recognition and prompt initiation of etiology-specific therapy, intensive care protocols, and liver transplantation are crucial for improving outcomes in patients with ALF 5.
- Cerebral edema and intracranial hypertension are major complications of ALF, and hypertonic saline and mannitol are used to manage these conditions 5.