#EMConf: Predicting the Need for Liver Transplant in Acetaminophen-induced Liver Failure

The most widely used criteria for predicting the need for liver transplant in patients with acetaminophen-induced liver failure are the King’s College Criteria (KCC), which are outlined below:

-pH< 7.3 or PT > 100 seconds AND Serum Cr > 3.4 AND Grade III or IV hepatic encephalopathy

The KCC, however, has drawn criticism, specifically regarding the low sensitivity of the prediction model. Thus, various other prediction models have been studied.

-One such study published in 2012 compared KCC, SOFA, APACHE II, MELD, and Lactate.

-In this study, the SOFA score outperformed the KCC, with an AUROC of 0.79 compared to 0.65 and sensitivity and specificity of 67% and 80% compared to 47% and 83%.

-Another study, published in Clinical Toxicology in 2018, sought to evaluate hypoglycemia as a prognostic indicator, comparing the KCC with the combination of hypoglycemia, coagulopathy, and lactic acidosis in predicting the endpoint of death or liver transplant.

-In this study, the combination of hypoglycemia, coagulopathy, and lactic acidosis outperformed the KCC, with an AUROC of 0.93 vs 0.77.  

Bottom Line:

-KCC is specific, but not sensitive

-SOFA score may provide better balance between specificity and sensitivity

-Hypoglycemia may prove to be a good prognostic indicator when combined with lactic acidosis and coagulopathy, though further studies would be needed to develop a clinical prediction tool







Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank's Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1163&se.... Accessed April 23, 2018.

Cholongitas E, Theocharidou E, Vasianopoulou P, et al. Comparison of the sequential organ failure assessment score with the Kings College Hospital criteria and the model for end-stage liver disease score for the prognosis of acetaminophen-induced acute liver failure. Liver Transplantation. 2012;18(4):405-412. doi:10.1002/lt.23370.

Levine M, Stellpflug SJ, Pizon AF, et al. Hypoglycemia and lactic acidosis outperform King’s College criteria for predicting death or transplant in acetaminophen toxic patients. Clinical Toxicology. May 2018:1-4. doi:10.1080/15563650.2017.1420193.