Acute liver failure in Sweden:: etiology and outcome

Wei G, Bergquist A, Broome U, Lindgren S, Wallerstedt S, Almer S, Sangfelt P, Danielsson A, Sandber-Gertzen H, Loof L, Prytz H, Bjomsson E (Sahlgrenska University Hospital, Gothenburg; Karolinska University Hospital, Huddinge, Stockholm; University Hospital MAS, Malmo; University Hospital, Linkoping; University Hospital, Uppsala; University Hospital, Umea; University Hospital, Orebro; Central Hospital, Vasteras; and University Hospital, Lund; Sweden). Acute liver failure in Sweden: etiology and outcome. J Intern Med 2007; 262: 393-401. Objective. To determine the causes and outcome of all patients with acute liver failure (ALF) in Sweden 1994-2003 and study the diagnostic accuracy of King's College Hospital (KCH) criteria and the model for end-stage liver disease (MELD) score with transplant-free deaths as a positive outcome. Research design and methods. Adult patients in Sweden with international normalized ratio (INR) of >= 1.5 due to severe liver injury with and without encephalopathy at admission between 1994-2003 were included. Results. A total of 279 patients were identified. The most common cause of ALF were acetaminophen toxicity in 42% and other drugs in 15%. In 31 cases (11%) no definite etiology could be established. The KCH criteria had a positive-predictive value (PPV) of 67%, negative-predictive value (NPV) of 84% in the acetaminophen group. Positive-predictive value and negative-predictive value of KCH criteria in the nonacetammophen group were 54% and 63% respectively. MELD score > 30 had a positive-predictive value of 21%, negative-predictive value of 94% in the acetaminophen group. The corresponding figures for the nonacetaminophen group were 64% and 76% respectively. Conclusions. Acetaminophen toxicity was the most common cause in unselected patients with ALF in Sweden. KCH criteria had a high NPV in the acetaminophen group, and in combination with MELD score < 30 predicts a good prognosis in acetaminophen patients without transplantation.