The King's College Criteria or the King's College Hospital criteria were devised in 1989 to determine if there were any early indices of poor prognosis in patients with acute liver failure. Acute liver failure is defined as the onset of encephalopathy (altered mental status) or coagulopathy (altered bleeding tendencies) within 26 weeks of a patient diagnosed with liver disease. Patients with hepatitis B acquired at birth, Wilson's disease and autoimmune hepatitis are included if their disease was identified within the past 26 weeks. These patients are very ill, and have a very high risk of dying of their illness without adequate treatment which may include liver transplantation. It is important that physicians find ways of identifying patients with acute liver failure early in their course who will do poorly, and may require liver transplantation. The King's College Criteria have consistently shown excellent operating characteristics for determining prognosis in these patients. As liver transplantation becomes a more accessible option for patients with acute liver failure, the King's College Criteria serve a role in determining which patients may require transplantation.[1]
The King's College criteria were described in a seminal publication in 1989 by J.G. O'Grady and colleagues from King's College School of Medicine.[2] 588 patients with acute liver failure who presented to King's College Hospital from 1973 to 1985 were assessed retrospectively to determine if there were particular clinical features or tests that correlated poorly with prognosis. The criteria were stratified into acetaminophen and non-acetaminophen causes of acute liver failure, due to the different operating characteristics of parameters correlating with prognosis in the two causes.[citation needed]
Paracetamol induced acute liver failureedit
Schematic of the metabolism of acetaminophen (paracetamol) by the hepatocyte.
Acetaminophen (or paracetamol) is an analgesic medication that can affect the liver when administered in high doses. Acetaminophen is predominantly conjugated into glucuronate and sulfate moieties by Phase II metabolism. A small percentage is metabolized by the cytochrome P450 pathway to a toxic metabolite, NAPQI. NAPQI is conjugated by glutathione to non-toxic cysteine and mercapturic acid moieties. In cases of acetaminophen toxicity, the Phase II conjugation enzymes are saturated, and a higher fraction is converted to NAPQI. The conjugation of NAPQI to glutathione occurs until glutathione is depleted from hepatic reserves, after which the toxic NAPQI accumulates and causes damage to the hepatocytes. This occurs primarily in areas of the liver that are relatively poorly perfused with oxygen, or furthest away from the hepatic artery, termed Zone 3. Acetaminophen overdose is associated with Zone 3 necrosis, to the point that acute liver failure may result.[3]
The King's College Criteria identify two groups of patients that have a poor prognosis with acetaminophen induced liver failure:
Arterial pH < 7.3 (taken by sampling of blood from an artery); or,
In patients with non-acetaminophen acute liver failure, the following criteria were identified as being associated with a poor prognosis:[2]
INR greater than 6.5; or,
Three of the following five criteria:
Patient age of less than 11 or greater than 40;
Serum bilirubin of greater than 300 micromoles per litre;
Time from onset of jaundice to the development of coma of greater than seven days;
INR greater than 3.5; or,
Drug toxicity, regardless of whether it was the cause of the acute liver failure.
Utility in predictionedit
The utility of the criteria in determining the prognosis of patients with acute liver failure is defined by their operating characteristics. The positive predictive value of the criteria in predicting death from acute liver failure has ranged from 70% to 100%.[1][7][8] A Canadian meta-analysis assessing various prognostic indices found that the specificity of the King's College criteria in predicting mortality exceeded 90%, with a sensitivity of 69%.[9] As a result, the American Society for Study of Liver Diseases has recommended the King's College Criteria as being helpful early parameters in ascertaining the need for liver transplantation in patients with acute liver failure.[1]
Alternativesedit
A variety of other calculations have been done based on similar parameters to determine the risk of mortality in acute liver failure.[1] The Acute Physiology and Chronic Health Evaluation II (APACHE II) score has a comparable sensitivity to the King's College Criteria in determining prognosis.[9]
Referencesedit
^ abcdefgPolson J, Lee W (2005). "AASLD position paper: the management of acute liver failure". Hepatology. 41 (5): 1179–97. doi:10.1002/hep.20703. PMID 15841455.
^ abcO'Grady J, Alexander G, Hayllar K, Williams R (1989). "Early indicators of prognosis in fulminant hepatic failure". Gastroenterology. 97 (2): 439–45. doi:10.1016/0016-5085(89)90081-4. PMID 2490426.
^Clark R, Borirakchanyavat V, Davidson A, Thompson R, Widdop B, Goulding R, Williams R (1973). "Hepatic damage and death from overdose of paracetamol". Lancet. 1 (7794): 66–70. doi:10.1016/S0140-6736(73)90466-2. PMID 4118649.
^Kanda D, Takagi H, Hashimoto Y, Yamazaki Y, Matsui M, Kosone T, Arai H, Ichikawa T, Nakajima H, Otsuka T, Kojima A, Sato K, Kakizaki S, Matsuzaki Y, Matsumoto T, Shimoda R, Kaneko M, Takayama H, Takahashi H, Abe T, Takezawa J, Mori M (2002). "Severe manifestation of acute hepatitis A recently found in Gunma, Japan". J Gastroenterol. 37 (7): 517–22. doi:10.1007/s005350200080. PMID 12162409.
^Alter M (1997). "Epidemiology of hepatitis C." Hepatology. 26 (3 Suppl 1): 62S–65S. doi:10.1002/hep.510260711. PMID 9305666.
^Kumar A, Beniwal M, Kar P, Sharma J, Murthy N (2004). "Hepatitis E in pregnancy". Int J Gynaecol Obstet. 85 (3): 240–4. doi:10.1016/j.ijgo.2003.11.018. PMID 15145258.
^Anand A, Nightingale P, Neuberger J (1997). "Early indicators of prognosis in fulminant hepatic failure: an assessment of the King's criteria". J Hepatol. 26 (1): 62–8. doi:10.1016/S0168-8278(97)80010-4. PMID 9148024.
^ abBailey B, Amre D, Gaudreault P (2003). "Fulminant hepatic failure secondary to acetaminophen poisoning: a systematic review and meta-analysis of prognostic criteria determining the need for liver transplantation". Crit Care Med. 31 (1): 299–305. doi:10.1097/00003246-200301000-00048. PMID 12545033.
April 18, 2024
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The King s College Criteria or the King s College Hospital criteria were devised in 1989 to determine if there were any early indices of poor prognosis in patients with acute liver failure Acute liver failure is defined as the onset of encephalopathy altered mental status or coagulopathy altered bleeding tendencies within 26 weeks of a patient diagnosed with liver disease Patients with hepatitis B acquired at birth Wilson s disease and autoimmune hepatitis are included if their disease was identified within the past 26 weeks These patients are very ill and have a very high risk of dying of their illness without adequate treatment which may include liver transplantation It is important that physicians find ways of identifying patients with acute liver failure early in their course who will do poorly and may require liver transplantation The King s College Criteria have consistently shown excellent operating characteristics for determining prognosis in these patients As liver transplantation becomes a more accessible option for patients with acute liver failure the King s College Criteria serve a role in determining which patients may require transplantation 1 Contents 1 Criteria 1 1 Paracetamol induced acute liver failure 1 2 Non paracetamol acute liver failure 2 Utility in prediction 3 Alternatives 4 ReferencesCriteria editThe King s College criteria were described in a seminal publication in 1989 by J G O Grady and colleagues from King s College School of Medicine 2 588 patients with acute liver failure who presented to King s College Hospital from 1973 to 1985 were assessed retrospectively to determine if there were particular clinical features or tests that correlated poorly with prognosis The criteria were stratified into acetaminophen and non acetaminophen causes of acute liver failure due to the different operating characteristics of parameters correlating with prognosis in the two causes citation needed Paracetamol induced acute liver failure edit nbsp Schematic of the metabolism of acetaminophen paracetamol by the hepatocyte Acetaminophen or paracetamol is an analgesic medication that can affect the liver when administered in high doses Acetaminophen is predominantly conjugated into glucuronate and sulfate moieties by Phase II metabolism A small percentage is metabolized by the cytochrome P450 pathway to a toxic metabolite NAPQI NAPQI is conjugated by glutathione to non toxic cysteine and mercapturic acid moieties In cases of acetaminophen toxicity the Phase II conjugation enzymes are saturated and a higher fraction is converted to NAPQI The conjugation of NAPQI to glutathione occurs until glutathione is depleted from hepatic reserves after which the toxic NAPQI accumulates and causes damage to the hepatocytes This occurs primarily in areas of the liver that are relatively poorly perfused with oxygen or furthest away from the hepatic artery termed Zone 3 Acetaminophen overdose is associated with Zone 3 necrosis to the point that acute liver failure may result 3 The King s College Criteria identify two groups of patients that have a poor prognosis with acetaminophen induced liver failure Arterial pH lt 7 3 taken by sampling of blood from an artery or All three of an international normalized ratio INR of greater than 6 5 serum creatinine of greater than 300 micromoles per litre and the presence of encephalopathy of grade III or IV These three are markers of coagulopathy kidney function and mental status 2 Non paracetamol acute liver failure edit nbsp Amanita phalloides the death cap mushroom is a cause of acute liver failureThere are many causes of acute liver failure aside from acetaminophen toxicity these include viral hepatitis including hepatitis A rarely 4 hepatitis B 1 hepatitis C rarely 5 hepatitis E especially in pregnant women 6 Epstein Barr virus cytomegalovirus and varicella zoster virus 1 Wilson s disease the toxin of the death cap mushroom Amanita phalloides alcohol autoimmune hepatitis Budd Chiari syndrome other medications including halothane hormonal contraception and isoniazid recreational drugs including ecstasy 1 and rarely tumours infiltrating the liver 1 In patients with non acetaminophen acute liver failure the following criteria were identified as being associated with a poor prognosis 2 INR greater than 6 5 or Three of the following five criteria Patient age of less than 11 or greater than 40 Serum bilirubin of greater than 300 micromoles per litre Time from onset of jaundice to the development of coma of greater than seven days INR greater than 3 5 or Drug toxicity regardless of whether it was the cause of the acute liver failure Utility in prediction editThe utility of the criteria in determining the prognosis of patients with acute liver failure is defined by their operating characteristics The positive predictive value of the criteria in predicting death from acute liver failure has ranged from 70 to 100 1 7 8 A Canadian meta analysis assessing various prognostic indices found that the specificity of the King s College criteria in predicting mortality exceeded 90 with a sensitivity of 69 9 As a result the American Society for Study of Liver Diseases has recommended the King s College Criteria as being helpful early parameters in ascertaining the need for liver transplantation in patients with acute liver failure 1 Alternatives editA variety of other calculations have been done based on similar parameters to determine the risk of mortality in acute liver failure 1 The Acute Physiology and Chronic Health Evaluation II APACHE II score has a comparable sensitivity to the King s College Criteria in determining prognosis 9 References edit a b c d e f g Polson J Lee W 2005 AASLD position paper the management of acute liver failure Hepatology 41 5 1179 97 doi 10 1002 hep 20703 PMID 15841455 a b c O Grady J Alexander G Hayllar K Williams R 1989 Early indicators of prognosis in fulminant hepatic failure Gastroenterology 97 2 439 45 doi 10 1016 0016 5085 89 90081 4 PMID 2490426 Clark R Borirakchanyavat V Davidson A Thompson R Widdop B Goulding R Williams R 1973 Hepatic damage and death from overdose of paracetamol Lancet 1 7794 66 70 doi 10 1016 S0140 6736 73 90466 2 PMID 4118649 Kanda D Takagi H Hashimoto Y Yamazaki Y Matsui M Kosone T Arai H Ichikawa T Nakajima H Otsuka T Kojima A Sato K Kakizaki S Matsuzaki Y Matsumoto T Shimoda R Kaneko M Takayama H Takahashi H Abe T Takezawa J Mori M 2002 Severe manifestation of acute hepatitis A recently found in Gunma Japan J Gastroenterol 37 7 517 22 doi 10 1007 s005350200080 PMID 12162409 Alter M 1997 Epidemiology of hepatitis C Hepatology 26 3 Suppl 1 62S 65S doi 10 1002 hep 510260711 PMID 9305666 Kumar A Beniwal M Kar P Sharma J Murthy N 2004 Hepatitis E in pregnancy Int J Gynaecol Obstet 85 3 240 4 doi 10 1016 j ijgo 2003 11 018 PMID 15145258 Shakil A Kramer D Mazariegos G Fung J Rakela J 2000 Acute liver failure clinical features outcome analysis and applicability of prognostic criteria Liver Transpl 6 2 163 9 doi 10 1002 lt 500060218 PMID 10719014 Anand A Nightingale P Neuberger J 1997 Early indicators of prognosis in fulminant hepatic failure an assessment of the King s criteria J Hepatol 26 1 62 8 doi 10 1016 S0168 8278 97 80010 4 PMID 9148024 a b Bailey B Amre D Gaudreault P 2003 Fulminant hepatic failure secondary to acetaminophen poisoning a systematic review and meta analysis of prognostic criteria determining the need for liver transplantation Crit Care Med 31 1 299 305 doi 10 1097 00003246 200301000 00048 PMID 12545033 Retrieved from https en wikipedia org w index php title King 27s College Criteria amp oldid 1219074153, wikipedia, wiki, book, books, library,
