title: Lessons from look-back in acute liver failure? A single centre experience of 3300 patients.
abstract: OBJECTIVE
  Acute liver failure (ALF) is a rapidly progressive critical illness with high mortality. Complex intensive care unit (ICU) protocols and emergency liver transplantation (ELT) are now often available, but rarity and severity of illness have limited its study and evidence-base for care. We reviewed patients treated over a 35-year period at a specialist high-volume ICU, quantifying changes in disease aetiology, severity and evolution of ICU support and ELT use and outcome.
  
  
  METHODS
  Review of adult patients admitted during the period 1973-2008, with acute liver dysfunction and coagulopathy with overt hepatic encephalopathy (ALF) and those without (acute liver injury; ALI).
  
  
  RESULTS
  3305 patients fulfilled inclusion criteria, 2095 with ALF. Overall hospital survival increased from 30% in 1973-78 to 76% in 2004-08; in ALF from 17% to 62% (both p<0.0001). In ALF patients treated without ELT, survival rose from 17% to 48% (p<0.0001); in those undergoing ELT (n=387) from 56% in 1984-88 to 86% in 2004-08 (p<0.01). Coincident with drug sales-restriction, paracetamol-related admissions fell significantly. Viral admissions fell from 56% to 17% of non-paracetamol cases (p<0.0001). Admission markers of liver injury severity fell significantly and the proportion of patients with intracranial hypertension (ICH) fell from 76% in 1984-88 to 20% in 2004-08 (p<0.0001). In those with ICH, mortality fell from 95% to 55% (p<0.0001).
  
  
  CONCLUSIONS
  The nature and outcome of ALF have transformed over 35 years, with major improvements in survival and a fall in prevalence of cerebral oedema and ICH, likely consequent upon earlier illness recognition, improved ICU care, and use of ELT.
authors: Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, United Kingdom. william.bernal@kcl.ac.uk
authors: William
authors: W
authors: Bernal
authors: Anna
authors: A
authors: Hyyrylainen
authors: Amit
authors: A
authors: Gera
authors: Vinod K
authors: VK
authors: Audimoolam
authors: Mark J W
authors: MJ
authors: McPhail
authors: Georg
authors: G
authors: Auzinger
authors: Mohammed
authors: M
authors: Rela
authors: Nigel
authors: N
authors: Heaton
authors: John G
authors: JG
authors: O'Grady
authors: Julia
authors: J
authors: Wendon
authors: Roger
authors: R
authors: Williams
mesh_terms: D000082:Acetaminophen / Q000009:adverse effects; D000328:Adult; D018712:Analgesics, Non-Narcotic / Q000009:adverse effects; D003422:Critical Care; D004630:Emergencies; D005260:Female; D006501:Hepatic Encephalopathy / Q000209:etiology / Q000401:mortality / Q000601:surgery; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology / Q000401:mortality / Q000601:surgery; D017114:Liver Failure, Acute / Q000209:etiology* / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation; D008131:London / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D055815:Young Adult
chemical_list: D018712:Analgesics, Non-Narcotic; D000082:Acetaminophen