s an indication for transplantation, fulminant A hepatic failure (FHF) accounts for approximately 7% of the liver transplantations currently performed in the United States and This percentage is very small in comparison with the number of transplants performed for chronic liver disease, but FHF dominates over other indications in terms of urgency, difficult decision-making, and the use of innovative approaches. The propensity for either precipitous deterioration or dramatic improvement in the condition of patients with this syndrome requires intensive patient monitoring and hour-byhour re-evaluation of their candidacy for transplantation. The major challenges facing clinicians are selecting in a timely fashion those patients who are not going to survive without a transplant and supporting them until a donor organ is found, which may take several days. The issues include candidacy, timing, and outcome.
It is clear that patients who are near death from FHF can be rescued by transplantation. Transplantation has had a significant impact on a disease that traditionally carried an 80% mortality in patients with advanced coma. Summarized in Table are the results of transplantation for FHF from several centers in North America. A handful of publications appeared in the late 1980s, and they reported patient survival rates ranging from 54% to 72%.3-11 In 1992, Lidofsky et al,12 from the University of California, San Francisco, reported a 92% survival rate in a small series of patients.
Candidacy
The syndrome of FHF encompasses an extremely heterogeneous group of entities in patients with widely different presentations. Recent reviews have