**4. Conclusion**

In an attempt to improve the prognostic accuracy in ALF patients, other indicators of liver dysfunction have been suggested, such as measures of hepatic metabolism with markers labeled with indocyanine green [25], as well as predictive models of mortality used in other clinical situations. The APACHE II system, designed to predict mortality in intensive care patients, has also been applied in ALF patients, but no cut point has been set demonstrating

A prognostic index designed by the ALFSG included variables at the time of presentation of the condition, such as bilirubin, encephalopathy grade, INR, phosphorus, and serum levels of M30 (a direct marker of hepatocyte apoptosis). Although the prognostic value of this index was greater than the KCC and MELD score, measurement of M30 is not generally available [27].

Comparison between these different models, which share some parameters, has found no superiority of one over the others, and no universal recommendations have been established. It is, however, accepted that ALF should be strictly assessed at the reception center and, if the patient meets the criteria for a poor prognosis, they should be referred as soon as possible to a transplant center where the available predictive models can be applied dynamically, mainly the KCC and Clichy criteria, to determine the indication for LT.American and European series show that 50% of patients admitted with ALF receive a LT [28]. Once the indication for a transplant has been made, the patient is included on the active list, in most countries with a higher priority than patients with other indications, thus ensuring an early transplant, usually within days of being placed on the list. If a donor organ becomes available, the situation of the patient should be reassessed by the transplant team, in order to identify a likely clear improvement after transplant or else an absolute contraindication for transplant, mainly the presence of irreversible brain damage.

In Europe LT due to acute or subacute liver failure accounts for some 8% of LT. Patient survival after LT for this reason is 79, 71, 69 and 61%, at 1, 3, 5 and 10 years, respectively [29]. This survival rate is slightly lower during the initial years (first and third) than LT for other reasons but then becomes similar. Most deaths occur between the first and third years posttransplant due, mainly, to neurologic complications and sepsis [30]. Some centers have reported survival rates of up to 86% [31]. Overall survival is probably greatly influenced by patient age, with data from the European Transplant Registry showing 1- and 5-year survival of 51 and 42% in

Multiple factors have been associated with the outcome of patients who receive a LT due to ALF. Three studies [4, 32, 33] have identified a recipient age above 45–50 years as a poor prognostic factor, attributing this to the reduction in physiologic reserve with effect from these ages [4]. A body mass index (BMI) >29 was identified in one study [32]. On the other hand, no specific factor associated with the severity of the ALF, such as coagulopathy, has been found to be associated with a poor prognosis, although the degree of kidney failure, mechanical ventilation, and the use of inotropic drugs were found to be predictive factors in these studies.

that it is superior to the KCC and nor can it be applied early on [26].

162 Liver Research and Clinical Management

**3. Outcome of liver transplant in acute liver failure**

patients older than 60 years [29].

**3.1. Factors influencing the results**

Acute liver failure is a potentially severe clinical condition that is associated with a high rate of mortality. Selection of those patients who will benefit from a liver transplant should be based on the early identification of prognostic factors. Survival of patients who receive a transplant due to ALF has improved over recent years, though it is still somewhat lower than that of patients who receive a LT for other reasons.
