Pediatric acute liver failure: variations in referral timing are associated with disease subtypes

In pediatric acute liver failure (PALF), rapid referral to a transplant center (TC) is advocated. Clinical variability of PALF may influence referral timing. We aimed to analyze early or late timing of referral in relation to clinical characteristics and outcome in PALF. We conducted a retrospective, single-center, comparative analysis of clinical and liver function parameters in two PALF cohorts (n = 23 per cohort): cohort 1 (early referral, duration of in-patient care before referral (DCR) <7 days) vs. cohort 2 (late referral, DCR a parts per thousand yenaEuro parts per thousand 7 days). Compared to late referrals, patients referred early were more frequently non-icteric and encephalopathic at initial presentation (n = 14 vs. 5 and n = 13 vs. 4, each p <0.05). Early referred PALF patients had lower hepatic encephalopathy (HE) grades and bilirubin (grade 1 vs. 2, p <0.02; 215 vs. 439 mu mol/l, p <0.001, respectively) but higher alanine aminotransferase (ALAT) levels (4,340 vs. 963 U/l, p <0.001). Cumulative poor prognostic indicators were lower in early referrals (2 vs. 4, p <0.001). In multivariate analysis, subacute liver failure (SLF > 7 days between disease onset and development of encephalopathy) was independently associated with late referral (relative risk 9.48; 95 % CI 1.37-64.85, p