5. Pediatric sub-acute hepatic failure in a developing country: risk factors that determine outcome

Abstract

Background and Aims: Sub-acute hepatic failure (SAHF) is a grey zone of liver dysfunction with variable course. Pediatric experience of SAHF is poorly highlighted in literature. We aimed to identify the risk factors that determine poor outcome of SAHF in children. Methods: Children admitted with SAHF were analysed. Poor outcome (PO: death or liver transplantation within 90 days) was compared with spontaneous recovery (SR: complete normalisation of liver functions in native liver). Pediatric End stage Liver Disease (PELD) and King's College Criteria (KCC) were applied to investigate their prognostic value. Results: Forty eight children with median age 6 (range, 2–16) years were enrolled. Etiological workup showed hepatitis A as most common etiology (15, 31%), Hepatitis B in 6 (12.5%), Hepatitis E in 1 (2%), Co-infection with hepatitis A and E in 7 (14.5%), Cytomegalovirus in 1 (2%) and Autoimmune hepatitis type 2 in 1 (2%), indeterminate in 15 (31%) while 2 (4%) children had incomplete evaluation. Twelve children (25%) had SR over a median period of 6 months (range, 1–24). Twenty eight (58.3%) children had PO while another 8 (16.7%) were recovering but lost to follow-up and excluded from analysis. Univariate analysis comparing PO and SR is shown in Table 1. On multivariate logistic regression analysis, only PELD score with a cut-off 32 (AUC: 0.833, sensitivity 68%, specificity 92%) predicted PO. King's college criteria (KCC) showed a sensitivity of 85.7%, specificity of 41.7%, positive predictive value of 77.4% and negative predictive value of 55.6% in our cohort. Conclusions: Hepatitis A is the most common etiology of SAHF in chldren. Non-viral etiology, hepatic encephalopathy, occurrence of infection and acute kidney injury determine PO. PELD score with a cut-off 32 has better specificity than KCC to predict PO. A significant proportion (42%) may escape liver transplantation. The authors have none to declare.