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King's College Criteria for Acetaminophen Toxicity

Calculators  Toxicology
It Recommends who should be immediately referred for liver transplant.
Arterial pH < 7.30
No 0
Yes 1
INR > 6.5 (PT > 100 sec)
No 0
Yes 1
Lactate > 3.5 mmol/L after fluid resuscitation (<4 hrs) OR lactate > 3 mmol/L after full fluid resuscitation (12 hours)
No 0
Yes 0
Phosphate > 3.75 mg/dL (1.2 mmol/L) at 48-96 hours
No 0
Yes 0


Measured Factor
Acetaminophen toxicity
Measured Factor Disease
  • Fulminant hepatic failure
Measured Factor Detail
KCC is a well-accepted criteria which show the degree of multiorgan dysfunction from acetaminophen-induced liver failure. The KCC can predict patients with poor prognosis. when used alone or with serum lactate and phosphate
Body System
Measured Factor Low Impact
  • Criteria 0, 1, 2 does not meet transplant or referral criteria
Measured Factor High Impact
  • Criteria 3 and 4 adviced to transfer to transplant center and list for transplant.

Result Interpretation

Ranges Ranges
Test Limitations
This criteria have low sensitivity and may fail to identify a proportion of patients who will die.
References: 2


Study Validation 1
The main aim of this study was to validate the King’s College Hospital (KCH) prognostic criteria in patients with acute liver failure (ALF). 177 patients were evaluated during a period of 13 years for ALF. The mean age of patients was 39 years and 63% among them were women. The main causes for ALF were viral hepatitis (31%), acetaminophen toxicity (19%), idiosyncratic drug reactions (12%), and miscellaneous causes (11%). 87 (49%) patients went for liver transplantation Patients were analyzed using KCH prognostic criteria and it had had high specificity and positive predictive value but low negative predictive value for a poor outcome. 87 (49%) patients went for liver transplantation. This study concludes that KCH criteria usually predicts a poor outcome and early prognostication is needed in patients with ALF to take decision of liver transplantation
References: 3
Study Validation 2
This single-centre study was conducted with the aim to evaluate the use of arterial blood lactate measurement for stratifying the potential candidates for transplantation in acute liver failure patients. 103 patients were studied and median was significantly higher in non-surviving patients than in survivors. Combined early and after fluid resuscitation concentrations had similar estimation as that of KCH criteria. This study concluded that arterial blood lactate measurement rapidly and accurately identifies patients who will die from paracetamol-induced acute liver failure diffrentating liver transplantation candidates
References: 4
Study Validation 3
The purpose of this study was to compare and summarize two different prognostic criteria used to evaluate the need for liver transplantation in patients with fulminant hepatic failure secondary to acetaminophen poisoning. Both the criteria were compared based on following parameters prothrombin time, creatinine, encephalopathy grade and it was found that king's criteria were more sensitive than pH: 69% (95% confidence interval, 63-75) vs. 57% (95% confidence interval, 44-68) . This study concluded that king’s method is more sensitive than other available tools for identifying candidates who need urgent liver transplantation surgery.
References: 5
Study Additional 1
This study was conducted in order to validate King’s College Hospital criteria (KCHC) in children with non-acetaminophen (APAP) induced pediatric acute liver failure (PALF). 163 patients were studied in this trial. Classification and Regression Tree (CART) analysis was utilized to find out any improvement in KCHC is associated with death vs. survival rate. The positive predictive value and negative predictive value of KCHC for this cohort was 33% and 88% respectively. Encephalopathy grade, International normalized ratio and total bilirubin were evaluating parameters in the study. Study concluded that KCHC does not reliably predict death in PALF and more parameters are needed to create a predictive model for PALF.
References: 6
Study Additional 2
A prospective, multicenter case study was conducted with aim to determine prognostic factors for pediatric patients with acute liver failure (ALF).  348 Children from birth to 18 years with ALF were included in the study. Primary outcome measures were death, death after transplantation, alive with native liver, and alive with transplanted organ. Study revealed that there were different causes for ALF in children than in adults. Further investigations are warranted to provide good prognostic markers.
References: 7


  1. O'grady JG, Alexander GJ, Hayllar KM, Williams R. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology. 1989;97(2):439-45.
  2. Dargan PI, Jones AL. Acetaminophen poisoning: an update for the intensivist. Crit Care. 2002;6(2):108-10.
  3. Shakil AO, Kramer D, Mazariegos GV, Fung JJ, Rakela J. Acute liver failure: clinical features, outcome analysis, and applicability of prognostic criteria. Liver Transpl. 2000;6(2):163-9.
  4. 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;359(9306):558-63.
  5. 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;31(1):299-305.
  6. Schiodt FV, Atillasoy E, Shakil AO, Schiff ER, Caldwell C, Kowdley KV,et al. Aetiology and outcome for 295 patients with acute liver failure in the United States. Liver Transpl Surg. 1999;5(1):29-34.
  7. Squires RH, Shneider BL, Bucuvalas J, Alonso E, Sokol R J, Narkewicz M R, et al. Acute liver failure in children: the first 348 patients in the pediatric acute liver failure study group. J Pediatr. 2006;148(5):652-658.

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