When should a decision to proceed with transplantation actually be made in cases of fulminant or subfulminant hepatic failure: at admission to hospital or when a donor organ is made available?

Abstract

The paper by Pauwels et al. in the current issue (1) is an excellent piece of work by a group of clinical investigators who have retrospectively examined the criteria proposed by two of the world's most pre-eminent liver transplant centers (2-4) for identifying patients admitted to the hospital for either fulminant (FHF) (onset 2 weeks but < 3 months to onset of encephalopathy) (5) who should be identified as candidates for liver transplantation because of their high rate of death without transplantation. The London criteria had been developed as a result of a retrospective analysis of over 280 cases with non-paracetamol-induced acute liver failure and then in a subsequent group of 54 patients with FHF not due to paracetamol (3,4). The Clichy criteria were originally developed as a result of a prospective study of 90 patients with acute viral hepatitis and a factor V value < 50% of the lower limit of normal (5). For the London criteria, the original studies reported a positive predictive value of 0.98, a negative predictive value of 0.82 and a predictive accuracy of 0.94 (3,4). For the Clichy data, the original report demonstrated a 0.90 positive predictive value for those with a coma or confusion and a positive predictive value of 0.89 for those without coma or confusion (5). The negative predictive value for the latter study was 0.94. In contrast to the original studies, when the criteria of these two transplant centers were applied to a population of 81 patients seen at the Hrpital Saint-Antoine between 1978 and 1988, the results achieved were considerably less good with the London criteria having a predictive accuracy of 0.79 and the Clichy criteria having a predictive accuracy of 0.73, both of which were less than the observed mortality rate of 0.81. The positive predictive accuracy of the London group was greater