King’s College Criteria for Non- Acetaminophen Toxicity acute hepatic failure

Identification of patients who should be immediately referred for liver transplant.

INR > 6.5 (Prothrombin time > 100 sec):

Patient age <11 or > 40 years:

Serum bilirubin level > 300 μmol/l:

More than seven days passed from the onset of jaundice to the development of encelopathy:

INR (international normalized ratio) >3.5 (prothrombin time > 50 seconds):

Etiology – the absence of hepatitis A and B or the presence of an idiosyncratic reaction to a drug:

Lactate >3.5 mmol/L after fluid
resuscitation (<4 hrs) OR lactate > 3
mmol/L after full fluid resuscitation (12 hours):


Phosphate > 3.75 mg/dL (1.2 mmol/L) at 48-
96 hours


Patient’s score Result Comment
0 0 0

Patients with acute liver failure should be treated in centers that specialize in the care of such patients. The King’s College criteria can help identify patients who require liver transplantation.

Criteria for non-acetaminophen-induced acute liver failure include:

  • 1 big criterion – International normalized ratio (INR)> 6.5; and
  • 5 small criteria:
    1. the patient’s age is <11 or> 40 years;
    2. the level of bilirubin in serum is more than 300 μmol per liter;
    3. More than seven days have passed from the onset of jaundice to the development of encelopathy;
    4. INR (international normalized ratio)> 3.5 (prothrombin time> 50 seconds);
    5. etiology – the absence of hepatitis A and B or the presence of an idiosyncratic reaction to a drug.

Interpretation of results:

A patient’s survival prognosis is poor if he has at least 1 major criterion or any 3 minor criteria.

The King’s College criteria are recommended by the American Association for the Study of Liver Diseases (AASLD) for determining the need for liver transplantation in patients with acute liver failure.

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  1. O’Grady JG, Alexander GJ, Hayllar KM, Williams R. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology. 1989 Aug;97(2):439-45. doi: 10.1016/0016-5085(89)90081-4. PMID: 2490426.
  2. Bernal W, Donaldson N, Wyncoll D, Wendon J. Blood lactate as an early predictor of outcome in paracetamol-induced acute liver failure: a cohort study. Lancet. 2002 Feb 16;359(9306):558-63. doi: 10.1016/S0140-6736(02)07743-7. PMID: 11867109.
  3. Bailey B, Amre DK, Gaudreault P. Fulminant hepatic failure secondary to acetaminophen poisoning: a systematic review and meta-analysis of prognostic criteria determining the need for liver transplantation. Crit Care Med. 2003 Jan;31(1):299-305. doi: 10.1097/00003246-200301000-00048. PMID: 12545033.
  4. Schmidt LE, Dalhoff K. Serum phosphate is an early predictor of outcome in severe acetaminophen-induced hepatotoxicity. Hepatology. 2002; 36(3):659–665. doi: 10.1053/jhep.2002.35069.
  5. Riordan SM, Williams R. Treatment of hepatic encephalopathy. N Engl J Med. 1997 Aug 14;337(7):473-9. doi: 10.1056/NEJM199708143370707. PMID: 9250851.

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