While King's Hospital Criteria (KCH) criteria are used worldwide, the Model for End-Stage Liver Disease (MELD) is a more recently developed scoring system that has been validated as an independent predictor of patient survival in conditions for liver transplantation (LT). The aim of the present study was to compare MELD and KCH criteria with other early clinical prognostic indicators (CPI) in a cohort of patients with fulminant hepatic failure (FHF). A total of 144 patients (mean age 31.7 Ϯ 14.7 yr; range 12-82 yr; 62 males) with FHF due to acute viral hepatitis were included into the study. Variables found significant on univariate analysis were entered into a multivariate logistic regression analysis. A total of 52 (36.1%) patients survived, the remaining 92 (63.9%) died. Univariate analysis showed that age, duration of jaundice, jaundice-encephalopathy interval (JEI), grade of encephalopathy, presence of cerebral edema, bilirubin, prothrombin time, creatinine, and MELD score were significantly different between survivors and nonsurvivors. Multivariate logistic regression identified 6 independent CPI of adverse outcome on admission: age Ն50 yr, JEI Ͼ7 days, grade 3 or 4 encephalopathy, presence of cerebral edema, prothrombin time Ն35 seconds, and creatinine Ն1.5 mg/dL. Presence of any 3 of 6 CPI was optimum in identifying survivors and nonsurvivors. A MELD score of Ն33 was found to be best discriminant between survivors and nonsurvivors by the construction of receiver operating characteristic (ROC) curves. See Editorial on Page 786Fulminant hepatic failure (FHF) is a complex multisystem illness that results after a catastrophic insult to the liver, manifesting in the development of a coagulopathy and encephalopathy within a short period of time.1 It carries high mortality rate with short-term transplantfree survival rate of 43%.2 Moreover, it accounts for about 7% of liver transplants among adults.3 Therefore, the determination of prognosis for accurately predicting the outcome in FHF is of immense value in establishing Abbreviations: KCH, King's College Hospital; MELD, Model for End-Stage Liver Disease; LT, liver transplantation; CPI, clinical prognostic indicators; FHF, fulminant hepatic failure; JEI, jaundice-encephalopathy interval; ROC, receiver operating characteristic curves; PPV, positive predictive value; NPV, negative predictive value; IgM, immunoglobulin M.

Sleep disturbances are common in patients of cirrhosis and has a significant effect on their health related quality of life (HRQOL). Thus far, no study has demonstrated a systematically studied significant correlation between the sleep disturbance observed and the neuropsychiatric impairment status of patients of cirrhosis. On the basis of PHES, we divided 100 cirrhotics into those having minimal hepatic encephalopathy (MHE) (PHES≤-5) and those not (NMHE). Now, in these MHE (n=46) and NMHE (n=54) patients, sleep disturbance was measured with Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) and HRQOL with SF-36(v2) questionnaire. Sixty (60 %) patients were found to be 'poor sleepers' (PSQI>5) while 38 (38 %) patients had excessive daytime sleepiness (ESS≥11). Univariate and multivariate analyses showed MHE has significant effect among 'poor sleepers' (P<0.0001) as well as on those with EDS (P<0.0001). Significant correlation existed between PHES and both the sleep parameters of PSQI (r = -0.518, P <0.0001) as well as ESS (r = -0.383, P <0.0001), implying independently strong correlation between poor cognition and the presence of night time sleep disturbance and excessive daytime sleepiness among cirrhotics. Significant correlation existed between PSQI and ESS and the various scales and component scores of SF-36(v2) signifying the negative impact of sleep disturbance on the HRQOL. In conclusion, both night time sleep disturbance and excessive daytime sleepiness have significant relation with the neuropsychiatric impairment in patients of cirrhosis and are significantly associated with the observed impairment in HRQOL.

AIH presenting as ACLF is not uncommon in Asian patients. A low threshold for liver biopsy is needed to confirm the diagnosis as nearly half the patients are seronegative. Early stratification to steroid therapy or liver transplantation (MELD>27; HE in ≥ F3) would reduce ICU stay and improve outcomes. This article is protected by copyright. All rights reserved.

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