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Published in Neel Sharma, Tiago Villanueva, Data Interpretation Made Easy, 2013
The King’s College criteria help to determine which patients who suffer from paracetamol-induced liver failure are at high risk from mortality and hence would benefit from a liver transplant: pH < 7.30and all three of: INR > 6.5serum creatinine > 300 mcmol/Lthe presence of grade 3 or 4 encephalopathy.
Performance of the paracetamol-aminotransferase multiplication product in risk stratification after paracetamol (acetaminophen) poisoning: a systematic review and meta-analysis
Published in Clinical Toxicology, 2023
Chun En Yau, Haoyang Chen, Bryant Po-Yuen Lim, Mingwei Ng, R. Ponampalam, Daniel Yan Zheng Lim, Yip Han Chin, Andrew Fu Wah Ho
This meta-analysis is the first to aggregate the data of all known studies about the paracetamol × AT multiplication product. The results provide information about the prognostic performance of the two well-established cut-off values of 1500 mg/L × IU/L and 10,000 mg/L × IU/L and provides a comprehensive overview of possible subgroups. It also presents optimal cut-off values for paracetamol × AT in different clinical scenarios where the nomogram cannot be used. Although there were no deaths or cases of acute liver failure reported in this study, this could be due to insufficient follow up time. There are reports of mortality and liver transplant in patients who have survived paracetamol poisoning in the longer term [41]. Using paracetamol × AT can help to identify more patients to undergo acetylcysteine treatment, which might hence have longer term benefits. Paracetamol × AT also accounts for many factors such as the time of ingestion, quantity of ingestion, and severity of ingestion into a single continuously valued variable, thus recognising the spectrum of severity in paracetamol poisoning unlike the Rumack-Matthew nomogram which only indicates two categories: high-risk and low-risk. It should be noted that other existent risk stratification tools, such as the King’s College criteria [42], are used to predict patients with fulminant hepatic failure who will benefit from liver transplantation. In paracetamol-overdose patients, the multiplication product can be used at an early stage of treatment to adjust acetylcysteine dosage accordingly, possibly complementing the use of the King’s College criteria.
Hypoglycemia and lactic acidosis outperform King’s College criteria for predicting death or transplant in acetaminophen toxic patients
Published in Clinical Toxicology, 2018
Michael Levine, Samuel J. Stellpflug, Anthony F. Pizon, David A. Peak, Janna Villano, Timothy Wiegand, Christian Dib, Stephen H. Thomas
For patients with severe acetaminophen-induced hepatotoxicity, liver transplantation is considered as a standard treatment for those not expected to survive [2]. In this study, the combination of hypoglycemia, lactic acidosis, and elevation of the PT were better predictors of the composite endpoint of death or transplant than the King’s College criteria, which has traditionally been widely regarded as the primary criteria to guide transplant. The use of the King’s College criteria, however, poses several significant challenges. First, the ideal time to institute transplant evaluation is prior to the development of encephalopathy. However, one of the entry criteria of the King’s College criteria is the presence of a grade III or IV hepatic encephalopathy. Waiting for the patients to have this degree of encephalopathy prior to instituting transplant evaluation is suboptimal, as the patient is not able to participate in the psychosocial assessment once encephalopathic. Furthermore, determining the degree of encephalopathy is somewhat subjective. In one study, by the time patients fulfilled the King’s College Criteria, many were felt to be medically unfit for surgery [7]. In addition, external interventions (e.g., hemodialysis) may artificially prevent patients from reaching all of the required end-points in the King’s College criteria. Thus, the use of the King’s College criteria may be suboptimal for many reasons. The modified King’s College criteria do incorporate arterial lactate. This modified criteria has slightly increased sensitivity but decreased specificity compared with the original King’s College criteria [8]. Furthermore, many of the same limitations with the original criteria still are applicable to the modified criteria.
Metabolic and mitochondrial treatments for severe paracetamol poisoning: a systematic review
Published in Clinical Toxicology, 2020
Michael E. Mullins, Lauren H. Yeager, William E. Freeman
These metabolic and mitochondrial treatments are unlikely to benefit the majority of patients with paracetamol overdoses who will have good outcomes with acetylcysteine. This is particularly true in the UK, where treatment now starts at the 100 line. We suggest considering additional treatment only for patients with at least one characteristic of severe poisoning. We suggest that may include any of the following: a paracetamol concentration above the 300 line, metabolic acidosis, positive King’s College criteria, or late presentation with evident liver injury and measurable paracetamol.