Original article
Systematic reviews and meta-analyses
Ability of King's College Criteria and Model for End-Stage Liver Disease Scores to Predict Mortality of Patients With Acute Liver Failure: A Meta-analysis

https://doi.org/10.1016/j.cgh.2015.10.007Get rights and content

Background & Aims

Several prognostic factors are used to identify patients with acute liver failure (ALF) who require emergency liver transplantation. We performed a meta-analysis to determine the accuracy of King's College criteria (KCC) versus the model for end-stage liver disease (MELD) scores in predicting hospital mortality among patients with ALF.

Methods

We performed a systematic search of the literature for articles published from 2001 through 2015 that compared the accuracy of the KCC with MELD scores in predicting hospital mortality in patients with ALF. We identified 23 studies (comprising 2153 patients) and assessed the quality of data, and then performed a meta-analysis of pooled sensitivity and specificity values, diagnostic odds ratios (DORs), and summary receiver operating characteristic curves. Subgroups analyzed included study quality, era, location (Europe vs non-Europe), and size; ALF etiology (acetaminophen-associated ALF [AALF] vs nonassociated [NAALF]); and whether or not the study included patients who underwent liver transplantation and if the study center was also a transplant center.

Results

The DOR for the KCC was 5.3 (95% confidence interval [CI], 3.7–7.6; 57% heterogeneity) and the DOR for MELD score was 7.0 (95% CI, 5.1–9.7; 48% heterogeneity), so the MELD score and KCC are comparable in overall accuracy. The summary area under the receiver operating characteristic curve values was 0.76 for the KCC and 0.78 for MELD scores. The KCC identified patients with AALF who died with 58% sensitivity (95% CI, 51%–65%) and 89% specificity (95% CI, 85%–93%), whereas MELD scores identified patients with AALF who died with 80% sensitivity (95% CI, 74%–86%) and 53% specificity (95% CI, 47%–59%). The KCC predicted hospital mortality in patients with NAALF with 58% sensitivity (95% CI, 54%–63%) and 74% specificity (95% CI, 69%–78%), whereas MELD scores predicted hospital mortality in patients with NAALF with 76% sensitivity (95% CI, 72%–80%) and 73% specificity (95% CI, 69%–78%). In patients with AALF, the KCC’s DOR was 10.4 (95% CI, 4.9–22.1) and the MELD score’s DOR was 6.6 (95% CI, 2.1–20.2). In patients with NAALF, the KCC’s DOR was 4.16 (95% CI, 2.34–7.40) and the MELD score’s DOR was 8.42 (95% CI, 5.98–11.88).

Conclusions

Based on a meta-analysis of studies, the KCC more accurately predicts hospital mortality among patients with AALF, whereas MELD scores more accurately predict mortality among patients with NAALF. However, there is significant heterogeneity among studies and neither system is optimal for all patients. Given the importance of specificity in decision making for listing for emergency liver transplantation, MELD scores should not replace the KCC in predicting hospital mortality of patients with AALF, but could have a role for NAALF.

Section snippets

Search Methodology

We conducted a systematic review of the literature by searching MEDLINE via PUBMED, Scopus, Web of Science, CINAHL and EMBASE for articles that reported on the diagnostic accuracy of KCC and MELD for ALF published between January 1, 2001 (because 2001 was the year that MELD was first validated as a predictor of outcome in chronic liver disease) and May 1, 2015. The search terms used were “Acute liver failure” OR “Fulminant liver failure,” “King’s Criteria” OR “King’s College Criteria” OR “Kings

Results

The search strategy identified 4063 potentially relevant studies. After screening their title and abstract, 311 were retrieved and evaluated. A further 9 studies were identified from the references of the articles evaluated and also reviewed. A total of 23 studies were found with enough information to go forward into a meta-analysis (Figure 1).19, 20, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54 The eligible studies evaluated a total of 2153 patients. KCC

Discussion

This meta-analysis confirms that when comparing KCC with MELD for outcome prediction in ALF, KCC have lower sensitivity and MELD lower specificity. However, the overall diagnostic accuracy of KCC and MELD in determining outcome as measured by DOR and sROC is comparable. The particular strength of the KCC seems to be in AALF where the DOR is twice that of MELD.

There is significant heterogeneity in the published studies for the performance of both prediction schemes but particularly for MELD,

Acknowledgments

Mark McPhail is grateful to the National Institute for Health Research, UK Biomedical Research Centre at Imperial College London for infrastructure support.

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  • Cited by (0)

    This article has an accompanying continuing medical education activity on page e44. Learning Objective–Upon completion of this activity, successful learners should be able to understand and explain the statistical terms commonly used in evaluating prognostic tests and in meta-analysis studies; compare the advantages and disadvantages of King's College Criteria and model for end-stage liver disease in acute liver failure prognosticating; differentiate when a high specificity or high sensitivity test is more important when deciding on the need for emergency liver transplantation; and be able to describe the potential sources of bias for performance of King's College Criteria and model for end-stage liver disease and how these can be quantified statistically.

    Conflicts of interest The authors disclose no conflicts.

    Funding Mark McPhail was supported by the Wellcome Trust, UK as part of a Postdoctoral Training Fellowship during the production of this article.

    a

    These authors contributed equally to this article.

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