Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London SE5 9RS, UK.
J Hepatol. 2010 Sep;53(3):492-9. doi: 10.1016/j.jhep.2010.03.023. Epub 2010 Jun 4.
BACKGROUND & AIMS: Current techniques for predicting outcome and requirement for emergency liver transplantation (ELT) in acute liver failure (ALF) are imperfect, though The Kings College Criteria (KCC) are the most commonly applied tools for this purpose. Their performance in identification of patients with non-paracetamol-induced ALF (non-POD ALF), who would not survive without ELT, has recently been questioned. Using quantitative techniques, we therefore performed a meta-analysis of outcome data of the KCC for prediction of survival in non-POD ALF.
A systematic database search was performed and retrieved articles graded according to a pre-agreed pro-forma of methodological quality. Collated data was meta-analysed for summary sensitivity, specificity, diagnostic odds ratio (DOR) and ROC curve analysis. Pre-specified sub-group analysis was performed on the basis of methodological quality, the severity of hepatic encephalopathy (HE) of reported patients, timing of KCC application and exclusion of those who underwent ELT.
Eighteen studies with data on 1105 patients were available for production of 2x2 tables. Summary sensitivity was 68 (95% CI 59-77)%, specificity 82 (75-88)% and DOR 12.6 (6.5-26.1). Heterogeneity was detected in the DOR and related to methodological quality (I(2)=64% for all studies versus 47% for 'good' quality studies) and was lower in studies considering high grade HE or dynamic application of KCC (I(2)=0%). For data where ELT were excluded (13 studies) summary sensitivity was 68 (57-79)%, specificity 81 (72-90)% and DOR 12.2 (4.9-30.1) and a symmetric summary ROC curve was produced. Specificity was highest in studies of patients with high grade HE (93 (80-100)%) and where KCC were applied dynamically through the clinical course (88 (78-97)%). Sensitivity was reduced in studies published post 2005 compared with studies pre 1995 (58 (46-71)% versus 85 (76-82)%).
KCC for outcome in non-POD ALF have good specificity and more limited sensitivity. There is significant heterogeneity in the published data partially related to methodological quality. KCC perform best in groups with high grade encephalopathy and in historically earlier studies suggesting modern medical management of ALF may modify performance of KCC.
目前，用于预测急性肝衰竭（ALF）患者预后和紧急肝移植（ELT）需求的技术并不完善，尽管 King's College 标准（KCC）是目前最常用于此目的的工具。最近，有人对 KCC 用于识别非对乙酰氨基酚诱导的 ALF（非 POD ALF）患者的能力提出了质疑，这些患者如果不进行 ELT 将无法存活。因此，我们使用定量技术对 KCC 用于预测非 POD ALF 患者生存的预后数据进行了荟萃分析。
系统地进行了数据库检索，并根据预先商定的方法学质量方案对检索到的文章进行了分级。对汇总数据进行了汇总敏感性、特异性、诊断比值比（DOR）和 ROC 曲线分析。根据方法学质量、报告患者肝性脑病（HE）的严重程度、KCC 应用时机以及排除接受 ELT 的患者，进行了预先指定的亚组分析。
共有 18 项研究提供了 1105 名患者的数据，可用于生成 2x2 表。汇总敏感性为 68%（95%CI 59-77%），特异性为 82%（75-88%），DOR 为 12.6（6.5-26.1）。DOR 存在异质性，与方法学质量有关（所有研究的 I(2)=64%，而“良好”质量研究的 I(2)=47%），并且在考虑高级别 HE 或 KCC 动态应用的研究中较低（I(2)=0%）。对于排除 ELT 的数据（13 项研究），汇总敏感性为 68%（57-79%），特异性为 81%（72-90%），DOR 为 12.2（4.9-30.1），并生成了对称的汇总 ROC 曲线。在高级别 HE 患者（93%（80-100%））和通过临床过程动态应用 KCC 的患者（88%（78-97%））中，特异性最高。与 1995 年以前的研究相比，2005 年以后发表的研究中敏感性降低（58%（46-71%）比 85%（76-82%））。
KCC 用于预测非 POD ALF 的预后具有良好的特异性和有限的敏感性。已发表的数据存在显著异质性，部分与方法学质量有关。在高级别脑病患者和历史上更早的研究中，KCC 表现最佳，这表明现代 ALF 治疗可能会改变 KCC 的性能。
