Fulminant hepatic failure: to transplant or not to transplant.

Despite progress in intensive care regimens and the introduction of various hepatic support procedures, the survival rate for fulminant hepatic failure remained around 20%. In the past few years, orthotopic liver transplantation has increased the survival rate to more than 50% and thus is generally considered the treatment of choice. However, since about 20% of the patients on standard therapy recover spontaneously, not all patients presenting with fulminant hepatic failure should undergo transplantation immediately. Therefore attempts should be made to identify the patients with "potentially reversible" liver disease in an early phase. In this article strategies for deciding which therapy fits the individual patient are proposed. The decision "to transplant or not to transplant" should be based on residual functioning liver-cell mass (e.g. factor V is less or greater than 15%), the presence or absence of systemic complications such as lactic acidosis and renal failure and the aetiology of the liver disease (e.g. reversible causes such as viral hepatitis B and irreversible causes such as Wilson's disease). A flow diagram has been constructed.