Prognosis and Transplantation
Table 5. Potentially Helpful Indicatorsa Patients With ALF
of Poor Prognosis in
Etiology Idiosyncratic drug injury Acute hepatitis B (and other non-hepatitis A viral infections) Autoimmune hepatitis Mushroom poisoning Wilson disease Budd-Chiari syndrome Indeterminate cause Coma Grade on Admission III or IV
King's College Criteria Acetaminophen-Induced ALF Strongly consider orthotopic liver transplantation (OLT) listing if: • Arterial lactate > 3.5 mmol/L after early fluid resuscitation
List for OLT if: • pH < 7.3 OR • Arterial lactate > 3.0 mmol/L after adequate fluid resuscitation
List for OLT if all 3 occur within a 24-hour period: • Presence of grade 3 or 4 hepatic encephalopathy • INR > 6.5 • Creatinine > 3.4 mg/dL
Non-Acetaminophen-Induced ALF List for OLT if: • INR > 6.5 and encephalopathy present (irrespective of grade) OR • Encephalopathy present, irrespective of grade, and any three of the following: ▶ Age < 10 or > 40 yearsb ▶ Jaundice for > 7 days before development of encephalopathyb ▶ INR ≥ 3.5 ▶ Serum bilirubin ≥ 17 mg/dL ▶ Unfavorable etiology, such as » Wilson Disease » Idiosyncratic drug reaction » Seronegative hepatitis
Please note: None of these factors, with the exception of Wilson Disease and possibly mushroom poisoning, is either necessary or sufficient to indicate the need for immediate liver transplantation. b These criteria, in particular, have not been found to be predictive of outcome in recent analyses.
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