Tag Archives: SOFA

When death is on the line

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“Never go against a Sicilian when death is on the line“! –from The Princess Bride

With acetaminophen-induced hepatic failure, King’s College Hospital (KCH) Criteria have been helpful for predicting death.  While the Sequential Organ Failure Assessment (SOFA) was not designed by a Sicilian (to the best of my knowledge), it is more sensitive at predicting death than KCH Criteria (Liver Transplantation 2012; 18: 405-412, & editorial 384-86) .

SOFA measures organ dysfunction by evaluating each of the following on a 0-4 scale: respiratory, hepatic, coagulation, cardiovascular, neurologic, and renal.

In the cited study, 125 consecutive adult patients (mean age 38 years) with acetaminophen-induced acute liver failure were evaluated.  KCH criteria had highest specificity (83%) and lowest sensitivity (47%).  The SOFA score had the best discriminative ability.  A SOFA score >7 during the first 96 hours predicted death or transplantation with a 95% sensitivity and 70.5% specificity.  Other specific predictors of poor outcome included higher lactate levels, worsened coagulation parameters, and need for mechanical ventilation.  In this cohort, 67 (54%) survived with medical management, 35 (28%) died and 23 (18%) received a liver transplant.

While sensitivity and specificity will vary based on pretest probability/specific population, what is clear is that relying on KCH criteria alone would be unwise.

Additional references:

  • -J Pediatr 2011; 159: 813.  Study of ALF in young infants.  38% were indeterminate, ~14% NH, 12% herpes.  n=148. 60% survived w/o OLT, 24% died, 16% OLT
  • -Hepatology 2010; 53: 567.  18% of indeterminate ALF may be due to acetaminophen toxicity.
  • The King’s College Criteria identify two groups of patients that have a poor prognosis with acetaminophen induced liver failure (http://en.wikipedia.org/wiki/King’s_College_Criteria)
  • -J Pediatr 2009; 155:801.  Diagnostic evaluation in ALF  –wide variation.  Often not tested for AIH, wilson’s, HAV, HBV
  • -NEJM 2009; 361: 2105.  Changes in FDA labeling of analgesics.  ~30,000 hospitalizations /yr due to acetaminophen overdose in U.S.  –1/2 inadvertent overdose.  Maximum dose -650mg.
  • -Hepatology 2007; 46: 966.  AASLD public policy.  It is leading cause of acute liver failure in U.S –50% of cases with 30% mortality rate.  500 deaths annually.  10% of cases may occur in those receiving the proper doses. In single year, acetaminophen causes more deaths than all the years of statins.
  • -JAMA 2006; 296: 87-93.  Prospective study of daily 4gm acetaminophen in healthy volunteers.  (stayed at research facility).  ALT >3 ULN in 38%.  Resolved over 6 days.
  • -Liver Transplantation 2006; 12: 682.
    -Hepatology 2005; 42: 1364-72.  74 pts died & 23 needed Tx during  6 yr period at 22 tertiary care centers.  48% of cases were unintentional overdoses.
  • -J Pediatr 2002; 140: 522.  Predictors of outcome p acetaminophen ingestion.