Paediatric acute liver failure: early outcome and evaluation of transplantation criteria in a Belgian transplantation centre

Abstract Background One of the challenges when caring for children admitted for acute liver failure (ALF) is to quickly identify those who will improve spontaneously and those for whom liver transplantation (LT) is the only therapeutic option. Methods Retrospective study to review our experience, identify mortality risk factors and update our LT criteria in case of paediatric ALF. Results 111 children were admitted between March 1989 and May 2021 (mean age 59.1 months). 28 children never met our LT criteria; 17 had contraindication to LT; 66 were registered on the LT waitlist. 14 of these 66 were subsequently withdrawn because of spontaneous liver function recovery; 11 died before having received a liver; 41 were transplanted. Hospital survival rate was 63% for the whole series, 98% for the children without LT criteria and 71% for the transplanted children. Univariate analysis identified cardiovascular and respiratory failures on admission, and grade 4–5 hepatic encephalopathy (HE) during stay significantly associated with death. Non-survivors also had, on admission and during their stay, significantly higher levels of lactate, ammonia and bilirubin and, during their stay, significantly more frequent prothrombin time ≤ 25% or international normalized ratio ≥ 4.0 than the survivors. Multivariate analysis identified grade 4–5 HE, lactate level on admission and ammonia peak level as significant mortality risk factors. Conclusion Our criteria identified almost all children who had the capacity to spontaneously recover their liver function and suggest that updated criteria should combine biological tests and signs of multiple organ failure.