Yadav Sanjay Kumar, Saraf Neeraj, Choudhary Narendra S, Sah Jayant Kumar, Sah Sujeet Kumar, Rastogi Amit, Bhangui Prashant, Saigal Sanjiv, Soin Arvinder Singh
Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, Delhi NCR, India.
Liver Transpl. 2019 Mar;25(3):459-468. doi: 10.1002/lt.25395.
Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute decompensation of previously diagnosed or undiagnosed liver disease with organ failure(s) with high short-term mortality. This study was conducted to report the outcomes of living donor liver transplantation (LDLT) in ACLF and assess the survival benefit of liver transplantation (LT) in these patients. It was a retrospective study of 218 ACLF patients on the basis of European Association for the Study of the Liver (EASL)-chronic liver failure criteria from January 2014 through November 2017. Patients were considered for LDLT if there was no improvement on standard medical therapy for 5-10 days. Prior to LDLT, active sepsis was excluded/treated, and renal, circulatory, and respiratory failures were improved to the greatest extent possible. The mean age was 42.9 years, and 181 patients were male. Sepsis was the most common acute precipitating event followed by alcohol. Of the patients, 35 (16.1%), 66 (30.3%), and 117 (53.7%) were classified into ACLF grades 1, 2, and 3, respectively. Although 80% of the ACLF 1 group and 72.7% of the ACLF 2 group underwent LDLT, only 35% of the ACLF 3 group could undergo LDLT. The circulatory and respiratory failures at admission were significantly higher in the nontransplant group with poor subsequent response to standard medical therapy, exclusion from LDLT, and poor outcomes. None of the patients on high support for circulatory and respiratory failure underwent LDLT. Posttransplant survival at 1 year was comparable among different grades of ACLF (92.9%, 85.4%, and 75.6%; P = 0.15). Among patients in the ACLF 3 group, survival at 90 days was extremely poor in those who could not undergo LDLT (5.9% versus 78%; P < 0.001). In conclusion, LDLT results in good survival with acceptable post-LT morbidity in patients with ACLF.
慢加急性肝衰竭（ACLF）是一种综合征，其特征为既往已诊断或未诊断的肝病急性失代偿，并伴有器官功能衰竭，短期死亡率高。本研究旨在报告ACLF患者活体肝移植（LDLT）的结果，并评估肝移植（LT）对这些患者的生存获益。这是一项回顾性研究，基于欧洲肝脏研究协会（EASL）慢性肝衰竭标准，纳入了2014年1月至2017年11月期间的218例ACLF患者。如果标准药物治疗5 - 10天无改善，则考虑患者进行LDLT。在LDLT之前，排除/治疗活动性脓毒症，并尽可能最大程度改善肾、循环和呼吸功能衰竭。平均年龄为42.9岁，181例患者为男性。脓毒症是最常见的急性促发事件，其次是酒精。患者中，分别有35例（16.1%）、66例（30.3%）和117例（53.7%）被分类为ACLF 1级、2级和3级。虽然ACLF 1组80%和ACLF 2组72.7%的患者接受了LDLT，但ACLF 3组只有35%的患者能够接受LDLT。非移植组入院时的循环和呼吸功能衰竭明显更高，对标准药物治疗后续反应差，被排除在LDLT之外，且预后不良。循环和呼吸功能衰竭需要高支持治疗的患者均未接受LDLT。不同等级的ACLF患者移植后1年生存率相当（92.9%、85.4%和75.6%；P = 0.15）。在ACLF 3组患者中，无法接受LDLT的患者90天生存率极低（5.9%对78%；P < 0.001）。总之，LDLT可使ACLF患者获得良好的生存，且移植后发病率可接受。
