Bernai et al modified the King's College Hospital (KCH) criteria for identifying a patient with poor prognosis following paracetamol (acetaminophen)-induced acute liver failure. This involves the addition of arterial lactate measurements during the initial fluid resuscitation. A patient meeting these criteria should be considered for liver transplantation. The authors are from King's College and St Thomas's Hospitals in London.


List for transplantation if one or more of the following is present:

(1) arterial pH < 7.3 after adequate fluid resuscitation (about 12 hours after hospital admission)

(2) arterial lactate concentration is > 3.0 mmol/L after adequate fluid resuscitation (about 12 hours after hospital admission)

(3) presence of all 3 of the following:

(3a) serum creatinine > 300 µmol/L (> 3.39 mg/dL)

(3b) INR > 6.5 (or PTT > 100 seconds)

(3c) hepatic encephalopathy of grade 3 or 4


Strongly consider listing for transplantation if:

(1) The arterial lactate concentration > 3.5 mmol/L after early fluid resuscitation (about 4 hours after admission to the hospital).



• The addition of arterial lactate concentration to the criteria gives a positive likelihood ratio of 15, which is similar to the original KCH criteria. The negative likelihood ratio for the modified criteria was < 2% in the validation group, which is an improvement over the original criteria.


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