Prognosis
ALF carries a substantial risk of mortality and continues to be a major challenge to clinicians as strategies to improve outcomes are developed. The sudden onset of disease and low incidence of ALF in the general population have limited our ability to study ALF in a prospective manner. However, data from the US Acute Liver Failure Study Group have provided insight into epidemiologic trends, outcomes, and the impact of therapies.
Epidemiologic studies have consistently demonstrated that the most important prognostic indicator in ALF is etiology.
Survival and outcomes
ALF secondary to acetaminophen overdose, acute hepatitis A, or ischemic liver injury is associated with a favorable prognosis. Approximately 70% of patients with acetaminophen-induced liver injury recover without liver transplantation.[132] In contrast, ALF resulting from idiosyncratic drug-induced liver injury, acute hepatitis B, or indeterminate cause has a much lower rate of spontaneous recovery, ranging from 25% to 41%.[13] Death or liver transplantation are more likely if ALF is secondary to hepatotoxicity caused by herbal and dietary supplements rather than hepatotoxicity caused by prescription drugs, possibly because patients taking herbal and dietary supplements are reluctant to seek medical help or slow to recognize the possible cause of their liver injury.[17][29][133]
A fulminant presentation of Wilson disease carries such a high risk of mortality that establishment of this diagnosis is sufficient to meet listing criteria for emergency liver transplantation.[42][129] Liver transplant candidacy should be assessed promptly in all patients who present with ALF, as this may be the only form of therapy that will have an impact on survival.
A low-factor V level in the presence of hepatic encephalopathy may be predictive of mortality, particularly in patients with ALF secondary to viral hepatitis.[62] In one prospective cohort of patients with ALF, it was noted that optimal factor V thresholds predictive of survival were >10.5% of normal in acetaminophen ALF and >22% of normal in non-acetaminophen ALF.[63]
Patients with ALF who undergo liver transplantation appear to have a higher risk of death within the first 3 months following transplant, and more commonly require retransplantation compared with elective cases.[129] However, the 1-year posttransplant survival rate in the US has improved over the last 10 years. Data from the US Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients indicate that patients with ALF who undergo liver transplantation have a 5-year survival rate of 93%.[111]
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