Selection for acute liver failure: Have we got it right?

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Abstract
Key Points 1 The interplay of four factors determines the outcome in Acute Liver Failure (ALF). Current criteria used for prognosis address each of these factors. a Hepatic regeneration: Age, poor prognostic etiologies (drug, idiopathic ALF) b Hepatocellular failure: INR, Bilirubin c Encephalopathy and brain edema: Stage III/IV, hyperacute vs acute/subacute d Multiorgan failure (MOF): pH 2 In hyperacute liver failure, exemplified by acetaminophen‐induced injury, prognostic criteria have focused on the course of encephalopathy and of multiorgan failure. In non‐acetaminophen induced ALF, prognostic criteria reflect a greater role of hepatic regeneration in outcome. 3 Prognostic indices combine features of these four factors. The Kings College criteria (KCC) have been shown to have a better performance than the Clichy criteria. The KCC appear to have a higher specificity than sensitivity for acetaminophen‐induced ALF, while its negative predictive value for non‐acetaminophen induced ALF is unfortunately low. 4 Newer prognostic markers have been proposed, including serum phosphate and alpha fetoprotein as markers of regeneration and blood lactate, a reflection of MOF and hepatocellular failure. They are likely to complement the KCC rather than replace them. 5 Clinical judgement is still needed to weigh management options in this disease. (Liver Transpl 2005;11:S30–S34.)