Acute liver failure is a devastating syndrome leading to development of rapid development (within 26 weeks) of jaundice, coagulopathy and hepatic encephalopathy or coma in patients without history of liver disease. Acute liver failure is an medical emergency associated with significant healthcare costs, resource utilisation, morbidity and mortality. Even in the modern age, it carries a mortality of close to 30%. Successful management depends on early identification of cause and cause directed therapy, timely access to high level intensive care management and organ support and timely application of liver transplantation in those unlikely to respond or unresponsive to best medical care. Liver transplantation has single handedly improved survival in acute liver failure from less than 50% in the 1960-1980 to a respectable 70-75% after the 1990s.
To be effective and efficient, liver transplant should be performed "never too early but never too late". Early transplant deprives the patient from a chance of spontaneous recovery of liver function and exposes him (and even a family donor) to a needless risk and operation as well as condemns the patient unnecessarily to lifelong medication and immunosuppression with all the associated problems. Too late transplant reduces the chances of recovery and increases the morbidity and mortality of the procedure.
It is therefore critical to identify the window in which medical management does seem to be improving condition but before the onset of infection, cerebral oedema or multi-organ failure .
Reams have been written on how to identify this window and there is still some debate. Most clinicians utilise a combination of clinical and laboratory criteria in deciding which patients are unlikely to improve without liver transplantation. The criteria commonly used are the King's college criteria, MELD/PELD score or Clichy criteria. The parameters most often used to decide are the degree of encephalopathy, prothrombin time, bilirubin, arterial ammonia and lactate levels. In small children with rapid development of coma monitoring of intracranial pressure may help identify those that could recover after liver transplantation. It must be remembered that these criteria are not infallible and are at best 80-85% accurate in determining prognosis ie 10-15% patients who meet these criterial may still recover spontaneously without transplant.
From a patient's point of view, it is important not to panic but to ensure timely transfer to a liver transplant facility since transferring patients with severe encephalopathy who need ventilator can lead to acceleration of brain swelling and death. Liver dialysis though widely popularised about a decade ago, seems to do little more that allow patients to wait longer for transplantation although there are anecdotal reports of spontaneous recovery in drug or toxin induced conditions.
While time is of the essence, a mad rush in deciding regarding liver transplantation particularly for a living donor is never prudent. All attempts should be made to get all the information, even seek more opinions if needed. It is undoubtedly a gruelling decision and there is a lot of pressure all around but you must look before you leap!
To be effective and efficient, liver transplant should be performed "never too early but never too late". Early transplant deprives the patient from a chance of spontaneous recovery of liver function and exposes him (and even a family donor) to a needless risk and operation as well as condemns the patient unnecessarily to lifelong medication and immunosuppression with all the associated problems. Too late transplant reduces the chances of recovery and increases the morbidity and mortality of the procedure.
It is therefore critical to identify the window in which medical management does seem to be improving condition but before the onset of infection, cerebral oedema or multi-organ failure .
Reams have been written on how to identify this window and there is still some debate. Most clinicians utilise a combination of clinical and laboratory criteria in deciding which patients are unlikely to improve without liver transplantation. The criteria commonly used are the King's college criteria, MELD/PELD score or Clichy criteria. The parameters most often used to decide are the degree of encephalopathy, prothrombin time, bilirubin, arterial ammonia and lactate levels. In small children with rapid development of coma monitoring of intracranial pressure may help identify those that could recover after liver transplantation. It must be remembered that these criteria are not infallible and are at best 80-85% accurate in determining prognosis ie 10-15% patients who meet these criterial may still recover spontaneously without transplant.
From a patient's point of view, it is important not to panic but to ensure timely transfer to a liver transplant facility since transferring patients with severe encephalopathy who need ventilator can lead to acceleration of brain swelling and death. Liver dialysis though widely popularised about a decade ago, seems to do little more that allow patients to wait longer for transplantation although there are anecdotal reports of spontaneous recovery in drug or toxin induced conditions.
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