Systematic review: prognostic tests of paracetamol‐induced acute liver failure

Abstract

SUMMARYBackground Paracetamol (acetaminophen) toxicity remains the leading cause of acute liver failure (ALF) in the developed world. In the UK, the recently modified King's College Criteria are used to list patients for emergency liver transplantation, but these criteria have been criticized for their low sensitivity and for spectrum bias in their application.

Acetaminophen hepatotoxicity: an updated review

“…The lactate modification, proposing that patients should be considered for transplantation with an early lactate >3.5 mmol/L or a post-resuscitation lactate >3 mmol/L, showed improved prognostic accuracy initially, but this finding was not reliably reproduced in subsequent studies (Craig et al 2010a). Small studies suggest promise with further modifications such as AFP, APACHE II scores, and serum IL-6, although further investigation is still needed (Craig et al 2010a). The Clichy criteria (Bernuau et al 1986) originally derived in patients with fulminant hepatitis B were subsequently found to be inferior to King's College in acetaminophen-induced disease (Izumi et al 1996).…”

“…Artificial support systems employ hemodialysis with adsorption to charcoal or albumin to remove toxins, while bioartificial systems use human or porcine hepatocytes for plasma filtration. These systems are currently used only in investigative trials, but meta-analyses have shown reduced bridging to transplantation in patients with acute-on-chronic liver failure with artificial systems and improved mortality in ALF with bioartificial systems (Craig et al 2010a;Bateman et al 2014c). …”

“…The King's College Criteria, developed by O'Grady and colleagues in 1989, has a high specificity for identifying patients that will require transplantation, but a poor negative predictive value with up to 26 % of patients unfit for surgery by the time they fulfill the criteria of either arterial pH < 7.3 or PT > 100 s (INR > 6.5) and Cr > 300 μmol/L (3.4 mg/dL) with Grade III or IV hepatic encephalopathy (Craig et al 2010a). The lactate modification, proposing that patients should be considered for transplantation with an early lactate >3.5 mmol/L or a post-resuscitation lactate >3 mmol/L, showed improved prognostic accuracy initially, but this finding was not reliably reproduced in subsequent studies (Craig et al 2010a). Small studies suggest promise with further modifications such as AFP, APACHE II scores, and serum IL-6, although further investigation is still needed (Craig et al 2010a).…”

Role of Liver Transplantation in Acute Liver Failure

“…Multiple prognostic models have been proposed to help determine the likelihood of spontaneous survival (Table 2) (Antoniades et al, 2007;Bailey et al, 2003;Bernuau et al, 1986b;Bernuau, 1993;Craig et al, 2010;Harrison et al, 1990;Itai et al, 1997;O'Grady et al, 1989;Pereira et al, 1992;Rolando et al, 2000;Schiodt et al, 2005;Van Thiel, 1993). However, many of these models are methodologically flawed and subject to bias.…”

Ability of King's College Criteria and Model for End-Stage Liver Disease Scores to Predict Mortality of Patients With Acute Liver Failure: A Meta-analysis

“…The first included only Acetaminophen-induced ALF (AALF) identifying nine studies in total, and concluded that the KCC had limited sensitivity 13 . A later study updated this meta-analysis for AALF to include a further five studies, and found that the KCC had high diagnostic accuracy 24 . However given previous reports have found the KCC to be superior in AALF than in the subset with Non-Acetaminophen-induced ALF (NAALF), 25 a later meta-analysis assessed the KCC in NAALF, again finding that the KCC have high overall accuracy and in particular good specificity if more limited sensitivity 26 .…”