Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada.
Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada.
Transplantation. 2021 Jul 1;105(7):1471-1481. doi: 10.1097/TP.0000000000003550.
Liver transplantation (LT) has revolutionized outcomes for cirrhotic patients. Current liver allocation policies dictate patients with highest short-term mortality receive the highest priority, thus, several patients become increasingly ill on the waitlist. Given cirrhosis is a progressive disease, it can be complicated by the occurrence of acute-on-chronic liver failure (ACLF), a syndrome defined by an acute deterioration of liver function associated with extrahepatic organ failures requiring intensive care support and a high short-term mortality. Successfully bridging to transplant includes accurate prognostication and prioritization of ACLF patients awaiting LT, optimizing intensive care support pre-LT, and tailoring immunosuppressive and anti-infective therapies post-LT. Furthermore, predicting futility (too sick to undergo LT) in ACLF is challenging. In this review, we summarize the role of LT in ACLF specifically highlighting (a) current prognostic scores in ACLF, (b) critical care management of the ACLF patient awaiting LT, (c) donor issues to consider in transplant in ACLF, and (d) exploring of recent post-LT outcomes in ACLF and potential opportunities to improve outcomes including current care gaps and unmet research needs.
肝移植（LT）彻底改变了肝硬化患者的预后。目前的肝脏分配政策规定，短期死亡率最高的患者应获得最高优先级，因此，一些患者在等待名单上的病情会逐渐恶化。鉴于肝硬化是一种进行性疾病，它可能会并发慢加急性肝衰竭（ACLF），这是一种定义为肝功能急性恶化的综合征，伴有需要重症监护支持的肝外器官衰竭，短期死亡率很高。成功桥接移植包括准确预测和优先考虑等待 LT 的 ACLF 患者，在 LT 前优化重症监护支持，并在 LT 后调整免疫抑制和抗感染治疗。此外，预测 ACLF 的无效性（太病重不能进行 LT）具有挑战性。在这篇综述中，我们总结了 LT 在 ACLF 中的作用，特别强调了：（a）ACLF 中的当前预后评分；（b）等待 LT 的 ACLF 患者的重症监护管理；（c）在 ACLF 中移植时需要考虑的供体问题；（d）探讨 ACLF 中最近的 LT 后结局以及改善结局的潜在机会，包括当前的护理差距和未满足的研究需求。
