Are King's College and Clichy-Villejuif criteria used for liver transplantation still appropriate? A retrospective study over a 25-year period.

Background: Acute liver injury (ALI) is a life-threatening condition that may require liver transplantation (LT). For over three decades, the King's College Hospital (KCH) and Clichy-Villejuif (CV) criteria have guided LT decisions, but their relevance in the modern intensive care unit (ICU) era remains uncertain. This study aimed to assess the "real-life" incidence of LT among ICU patients with ALI fulfilling these criteria. We retrospectively analysed prospectively collected data from 2000 to 2025 in a tertiary ICU with an active LT program. All consecutive adult patients with ALI fulfilling KCH and/or CV criteria without contraindications were included. The primary endpoint was the incidence of LT. Secondary endpoints included ICU and one-year survival, organ support requirements, temporal trends and transplant-free survival according to criteria fulfilment. Results: Among 396 patients with ALI, 118 fulfilled KCH and/or CV criteria without contraindications for LT. The incidence of LT was 34% (40 out of 118). ICU and one-year survival did not significantly differ between transplanted and not transplanted patients (88% vs. 92% and 85% vs. 81%, respectively). Transplanted patients had more severe liver dysfunction, reflected by higher MELD scores driven by higher values of bilirubin and INR. They were more likely to have auto-immune hepatitis (23% vs. 1%, p < 0.01), and less likely to have acetaminophen-induced (25% vs. 46%, p = 0.03) or ischaemic ALI (2% vs. 26%, p < 0.01). Encephalopathy progression was more frequent in transplanted patients. The delay between ICU admission and LT significantly increased over the study period. Among not transplanted patients, one-year transplant-free survival exceeded 80% overall and remained high across all KCH/CV fulfilment patterns. Conclusion: In our cohort, only one-third of ALI patients fulfilling emergency LT criteria underwent transplantation. These findings suggest that historical KCH and CV criteria have limited ability to identify patients with poor prognosis without LT in the context of modern intensive care.