Artru Florent, Samuel Didier
Liver Unit, CHRU Lille, France, University of Lille, LIRIC team, Inserm unit 995.
AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Villejuif, F-94800, France; Univ Paris-Sud, UMR-S 1193, Université Paris-Saclay, Villejuif, F-94800, France; Inserm, Unité 1193, Université Paris-Saclay, Villejuif, F-94800, France; Hepatinov, Villejuif, F-94800, France.
JHEP Rep. 2019 Feb 23;1(1):53-65. doi: 10.1016/j.jhepr.2019.02.008. eCollection 2019 May.
In the era of the "sickest first" policy, patients with very high model for end-stage liver disease (MELD) scores have been increasingly admitted to the intensive care unit with the expectation that they will receive a liver transplant (LT) in the absence of improvement on supportive therapies. Such patients are often admitted in a context of acute-on-chronic liver failure with extrahepatic failures. Sequential assessment of scores or classification based on organ failures within the first days after admission help to stratify the risk of mortality in this population. Although the prognosis of severely ill cirrhotic patients has recently improved, transplant-free mortality remains high. LT is still the only curative treatment in this population. Yet, the increased relative scarcity of graft resource must be considered alongside the increased risk of losing a graft in the initial postoperative period when performing LT in "too sick to transplant" patients. Variables associated with poor immediate post-LT outcomes have been identified in large studies. Despite this, the performance of scores based on these variables is still insufficient. Consideration of a patient's comorbidities and frailty is an appealing predictive approach in this population that has proven of great value in many other diseases. So far, local expertise remains the last safeguard to LT. Using this expertise, data are accumulating on favourable post-LT outcomes in very high MELD populations, particularly when LT is performed in a situation of stabilization/improvement of organ failures in selected candidates. The absence of "definitive" contraindications and the control of "dynamic" contraindications allow a "transplantation window" to be defined. This window must be identified swiftly after admission given the poor short-term survival of patients with very high MELD scores. In the absence of any prospect of LT, withdrawal of care could be discussed to ensure respect of patient life, dignity and wishes.
在“病情最重者优先”政策的时代，终末期肝病（MELD）评分极高的患者越来越多地被收入重症监护病房，期望在支持性治疗无改善的情况下能接受肝移植（LT）。这类患者常因慢性肝功能衰竭急性发作并伴有肝外器官功能衰竭而入院。入院后最初几天内根据器官功能衰竭进行评分的连续评估或分类有助于对该人群的死亡风险进行分层。尽管近期重症肝硬化患者的预后有所改善，但无移植情况下的死亡率仍然很高。LT仍是该人群唯一的治愈性治疗方法。然而，在对“病情过重无法移植”的患者进行LT时，必须考虑到移植物资源相对稀缺性增加以及术后初期失去移植物的风险增加。大型研究已确定了与LT术后近期不良结局相关的变量。尽管如此，基于这些变量的评分表现仍不充分。考虑患者的合并症和虚弱状况在该人群中是一种有吸引力的预测方法，在许多其他疾病中已证明具有重要价值。到目前为止，当地的专业知识仍然是LT的最后一道保障。利用这一专业知识，关于MELD评分极高人群LT术后良好结局的数据正在积累，特别是在选定的候选人器官功能稳定/改善的情况下进行LT时。不存在“绝对”禁忌证以及对“动态”禁忌证的控制使得可以定义一个“移植窗口”。鉴于MELD评分极高的患者短期生存率较低，入院后必须迅速确定这个窗口。在没有LT前景的情况下，可以讨论停止治疗以确保尊重患者的生命、尊严和意愿。
