Liver transplantation in acute liver failure: A challenging scenario

Table 1 Comparison between different prognostic scoring systems for acute liver failure

Ref.	n	Etiologies	Parameters		Comments
			Laboratory	Clinical
Bernuau et al[8] (1986)	115	Hepatitis B	Factor V levels	Age	Clichy criteria
O´Grady et al[11] (1989)	332	Non-paracetamol	Bilirubin, INR	Age, etiology, jaundice to encephalopathy > 7	First model to differentiate between paracetamol-induced and other etiologies
	431	Paracetamol	Arterial pH, Creatinine, INR, grade 3-4 encephalopathy
Bismuth et al[63] (1996)	139	All patients	Factor V levels	Age, grade 3-4 encephalopathy
Mitchell et al[30] (1998)	102	Paracetamol	APACHE II		APACHE II score > 15: sensitivity 82%, specificity 98%; similar to KCC
Schmidt et al[37] (2002)	125	Paracetamol	Serum phosphate > 1.2 mmol/L		Applicable from day 2-4 after overdose; sensitivity 89%, specificity 100%; superior to KCC
Bernal et al[24] (2002)	210	Paracetamol	Lactate		Addition of post resuscitation lactate to KCC improved sensitivity
Larson et al[46] (2005)	275	Paracetamol	APACHE II		APACHE II score > 20: sensitivity 68%, specificity 87%; superior to KCC
Ganzert et al[44] (2005)	198	Amanita phalloides	Prothrombin time < 25%, creatinine > 1.2 mg/dL		Applicable from day 3 after ingestion; sensitivity 100%, specificity 98%
Schmidt et al[36] (2005)	239	Paracetamol	α-fetoprotein		Dynamic α-fetoprotein measurement
Schiødt et al[41] (2005)	252	All patients	Actin-free Gc-globulin		Cutoff level 40 mL/L; similar prognostic information as KCC in a single measurement admission
Taylor et al[45] (2006)	29	Hepatitis A	ALT ≤ 2600 IU/L, creatinine ≥ 2.0 mg/dL	Intubation, vasopressors requirement	Superior to MELD score and KCC
Schiødt et al[35] (2007)	206	All patients	α-fetoprotein ratio day 1 and 3		Ratio ≥ 1 indicated better prognosis
Antoniades et al[40] (2006)	70	Paracetamol	Monocyte HLA-DR ≤ 15%
Yantorno et al[13] (2007)	64	Non-paracetamol	MELD score		MELD superior to KCC and Clichy criteria
Dhiman et al[32] (2007)	144	Acute viral hepatitis	Creatinine ≥ 1.5 mg/dL, prothrombin time ≥ 35 s	Age ≥ 50, jaundice to encephalopathy > 7, cerebral edema, grade 3-4 encephalopathy	Presence of any of three variables superior to KCC and MELD score
Schimdt and Larsen[31] (2007)	460	Paracetamol	Serial MELD score		MELD score did not provide more information than KCC or INR alone
Escudié et al[43] (2007)	27	Amanita phalloides	INR > 6 at day 4	Ingestion diarrhea interval < 8 h	Encephalopathy not needed to decide transplantation
Volkmann et al[38] (2008)	70	All patients	Caspase activation (measured by Cytokeratin 18 fragments, M30 and M65)		Caspase activity might predict spontaneous recovery
Mochida et al[15] (2008)	698	All patients	Prothrombin time < 10%, bilirubin ≥ 18 mg/dL	Age ≥ 45, jaundice to encephalopathy ≥ 11 d	Re-evaluates within 5 d if patient remains alive and liver transplantation was not performed
Hadem et al[14] (2008)	102	All patients	Bilirubin, lactate	Etiology	Bile score, better prognostic accuracy than MELD score or KCC
Bechmann et al[33] (2010)	68	All patients	Cytokeratin 18 (M65), creatinine, INR		MELD-M65 score
Westbrook et al[42] (2010)	54	Pregnancy-related	Lactate ≥ 2.8 mg/dL	Encephalopathy	Sensitivity 90%, specificity 86%; superior to KCC
Cholongitas et al[28] (2012)	125	Paracetamol	SOFA score, APACHE II score, KCC, MELD		SOFA score was superior to KCC, MELD and APACHE II
Rutherford et al[34] (2012)	500	All patients	INR, bilirubin, phosphorus ≥ 3.7 mg/dL, log10 M30	Encephalopathy grade	ALFSG index sensitivity 86% and specificity 65%; superior to MELD score and KCC
Mendizabal et al[6] (2014)	154	Non-paracetamol	MELD score		MELD superior to KCC and Clichy criteria

ALFSG: Acute liver failure study group; ALT: Alanine aminotransferase; APACHE: Acute physiology and chronic evaluation; INR: International normalized ratio; KCC: King’s College Criteria; MELD: Model for end-stage liver disease.

Table 2 Variables that correlate with outcome in patients with acute liver failure

Clinical/demographic	Serologic
Age	Bilirubin	Phosphate
Encephalopathy	Creatinine	Ketone body ratio
Etiology	INR/factor V	α-fetoprotein
Cerebral edema	Lactate	Cell death markers
Jaundice to encephalopathy interval	pH	(M30, M65)
Mechanical ventilation	Gc globulin	Monocyte HLA-DR
Vasopressors requirement
Functional/physiologic	Morphologic
APACHE II	Hepatocyte necrosis
Hepatic artery resistance index changes	Liver volume

Table 3 Determinants associated with poor outcomes following liver transplantation in patients with acute liver failure

Demographic	Graft-related	Clinical
Age > 45 yr	Donor > 60 yr	Vasopressors
Male sex	ABO mismatch	Creatinine
Non-viral etiology	Steatosis	Body mass index ≥ 30 kg/m2
	Reduced liver

Table 4 One-year survival following liver transplantation depending on the type of graft used

	OLT[3]	LDLT[35,39]	ABO-incompatible[50]	Auxiliary LT[45]
Graft	73%	70%	64%	53%
Patient	79%	70%-79%	69%	62%

LDLT: Living-donor liver transplantation; LT: Liver transplantation; OLT: Orthotopic liver transplantation.