Acute liver failure: transplant assessment (adult)
INR 1.5 or more with any encephalopathy, no prior liver disease, illness less than 26 weeks. Children: paediatric liver transplant unit.
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Hepatobiliary SurgeryDiagnostic
Acute Liver Failure - Transplant Criteria (King's College)
Acute Liver Failure - Transplant Criteria (King's College): Acute liver failure: transplant assessment (adult) → Call the liver transplant unit now. Do ...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Warning Call the liver transplant unit now. Do not wait for King's criteria
Transfer early: patients can become too unstable to move.
- Any encephalopathy in acute liver injury: arrange transfer to a transplant centre
- Paracetamol: call if INR >3.0 at 48 h or >4.5 at any time; creatinine >200 µmol/L or oliguria; pH <7.3 or lactate >3 mmol/L
- Paracetamol: also call if SBP <80 mmHg after fluids, hypoglycaemia, severe thrombocytopenia, or GCS <15 not due to sedatives
03Action ICU care while you arrange transfer
ICU for grade 2 or higher encephalopathy. Do not correct INR routinely: it is a key prognostic marker. INR is not valid on warfarin or after plasma or factor products.
- Blood products only for active bleeding or before a high-risk procedure, after discussion with the transplant unit
- Check glucose often. Hypoglycaemia: continuous glucose 10% infusion
- Grade 3-4 encephalopathy: intubate for airway protection
- Infection signs are often absent. Regular cultures; no routine prophylaxis. Sepsis, persistent hypotension or worse encephalopathy: empiric broad-spectrum antibiotics; consider antifungal
- Raised ICP: hypertonic saline or mannitol. Mannitol: not with anuria or severe hypovolaemia; monitor serum osmolality
- Avoid low sodium. Correct low sodium slowly: no more than 6-8 mmol/L in 24 h
- Grade 2 or higher encephalopathy: consider early CRRT for high ammonia
- Hypotension after fluids: noradrenaline first line; add vasopressin if needed
- ICP monitoring only in selected patients at expert centres
04Decision Is paracetamol the cause?
Paracetamol level may be undetectable at presentation. Suspect it with staggered or unknown-time ingestion.
- If Yes
- Paracetamol
05Action Paracetamol ALF: continue IV acetylcysteine
Give or continue IV acetylcysteine. Dose and stop rules: ANZ paracetamol guideline (Chiew 2020). Poisons Information Centre 13 11 26.
06Decision Paracetamol King's: pH <7.30, or INR >6.5 + creatinine >300 µmol/L + HE 3-4?
Any one of these. Not for cirrhosis or acute-on-chronic liver failure. INR not valid on warfarin or after plasma or factor products: tell the transplant unit.
- Arterial pH <7.30 after fluid resuscitation
- OR all 3 on the same day: INR >6.5, creatinine >300 µmol/L, grade 3-4 encephalopathy
- Arterial lactate >3.5 mmol/L about 4 h after admission, or >3.0 mmol/L after fluids (about 12 h), predicts death: tell the transplant unit
- If Yes
- Criteria met
07Action Criteria met: urgent transplant listing by the transplant unit
Australia and NZ: urgent listing on OrganMatch. Category 1 if ventilated in ICU; Category 2a if not yet ventilated. Listing lapses after 72 h unless the unit relists.
- Transfer to the liver transplant unit if not already there
- The unit assesses contraindications and futility
- Continue full ICU care while waiting
- Reassess often: some patients improve and are delisted; some become too sick for transplant
08Action Liver transplant
Listed patients: transplant when a suitable liver is available.
09End Outcome
Post-transplant care or recovery follow-up
If No- Not met
10Action Criteria not met: continue ICU care and reassess
Not meeting criteria does not mean safe: King's criteria miss some patients who die. Keep the transplant unit involved.
- Repeat INR, arterial pH, lactate, creatinine, bilirubin, glucose and encephalopathy grade often
- Reapply the criteria at each review
- MELD >25 or high lactate: high risk; ask the transplant unit about listing
11Decision On review: criteria now met, or transplant unit advises listing?
- If Yes
- Now meets criteria
- Path rejoins step 07Shared downstream outcome
If No- Not met
12Action Not listed: supportive care until recovery
Criteria still not met: continue ICU care until INR and encephalopathy improve. If worse, reapply criteria and call the transplant unit.
- Path rejoins step 09Shared downstream outcome
If No- Not paracetamol
13Action Not paracetamol: treat the cause now
Start cause-specific treatment while you apply the criteria.
- Adults: IV acetylcysteine (benefit seen with grade 1-2 encephalopathy). Not for children with non-paracetamol ALF
- Suspected herpes simplex or zoster: IV aciclovir now, before PCR results
- Amanita (death cap) mushrooms: Poisons Information Centre 13 11 26 (also for silibinin supply); IV silibinin as soon as possible; if not available, IV benzylpenicillin
- Hepatitis B: entecavir or tenofovir
- Autoimmune hepatitis: IV corticosteroids (specialist); do not delay transplant assessment
- Budd-Chiari: IV heparin unless contraindicated
- Drug-induced: stop the drug
14Warning King's criteria do not apply here: start transplant assessment early
Also not valid in acute-on-chronic liver failure or cirrhosis.
- Wilson disease: start transplant assessment at diagnosis; medical therapy rarely works
- Pregnancy (AFLP, HELLP): prompt delivery with obstetrics; transplant assessment if no improvement after delivery
- Autoimmune hepatitis or Amanita poisoning: early transplant assessment, before criteria are met
15Decision Non-paracetamol King's criteria met? INR >6.5, or 3 of 5 risk factors
Any one of these. Not for cirrhosis or acute-on-chronic liver failure. INR not valid on warfarin or after plasma or factor products: tell the transplant unit.
- INR >6.5, any encephalopathy grade
- OR 3 of 5: age <11 or >40 years; bilirubin >300 µmol/L; jaundice >7 days before encephalopathy; INR >3.5; cause is drug reaction or indeterminate (non-A non-B) hepatitis
- MELD >25 also means high risk: discuss listing with the transplant unit even if King's criteria are not met
- If Yes
- Criteria met
- Path rejoins step 07Shared downstream outcome
If No- Not met
- Path rejoins step 10Shared downstream outcome
Guideline Source
ACG Clinical Guideline: Acute Liver Failure (Shingina et al., Am J Gastroenterol 2023)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- King's criteria are specific but miss some patients who die: involve the transplant unit early, whether or not criteria are met
- Not validated for Wilson disease, pregnancy-related ALF, Amanita poisoning, acute-on-chronic liver failure or children
- Developed before modern ICU care and early CRRT; transplant-free survival is now higher than first reported
- Listing decisions, contraindications and futility are for the liver transplant unit
Contraindicated Populations
Children: use a paediatric liver transplant unit pathwayChronic liver disease or cirrhosis (acute-on-chronic liver failure): King's criteria do not applyPregnancy-related ALF (AFLP, HELLP): obstetric emergency; prompt delivery first
Applicable Regions
AUNZUSUKEU
AU: Urgent liver listing is binational (Australia and NZ) under TSANZ Deceased Donor Guidelines: Category 1 (ventilated in ICU) or 2a (meets King's criteria, not ventilated). Poisons Information Centre 13 11 26.
EU: EASL Clinical Practice Guidelines on acute liver failure (2017).
NZ: Binational urgent listing with Australia under TSANZ guidelines; National Poisons Centre 0800 764 766.
UK: NHSBT super-urgent liver listing criteria apply.
US: UNOS Status 1A listing; ACG 2023 guideline.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Acute Liver Failure - Transplant Criteria (King's College)?
The Acute Liver Failure - Transplant Criteria (King's College) is a diagnostic clinical algorithm for Hepatobiliary Surgery. It provides a structured decision tree to guide clinical decision-making, based on ACG Clinical Guideline: Acute Liver Failure (Shingina et al., Am J Gastroenterol 2023).
What guideline is the Acute Liver Failure - Transplant Criteria (King's College) based on?
This algorithm is based on ACG Clinical Guideline: Acute Liver Failure (Shingina et al., Am J Gastroenterol 2023) (DOI: 10.14309/ajg.0000000000002340).
What are the limitations of the Acute Liver Failure - Transplant Criteria (King's College)?
Known limitations include: King's criteria are specific but miss some patients who die: involve the transplant unit early, whether or not criteria are met; Not validated for Wilson disease, pregnancy-related ALF, Amanita poisoning, acute-on-chronic liver failure or children; Developed before modern ICU care and early CRRT; transplant-free survival is now higher than first reported; Listing decisions, contraindications and futility are for the liver transplant unit. Individual patient factors may require deviation from these recommendations.
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