Sacleux Sophie-Caroline, Saliba Faouzi
Hepato-Biliary Center, AP-HP Paul Brousse Hospital, Paris-Saclay University, INSERM Unit N°1193, 94800 Villejuif, France.
Life (Basel). 2023 May 10;13(5):1152. doi: 10.3390/life13051152.
Cirrhotic patients who developed a decompensation episode requiring an admission to an intensive care unit are not equal in term of prognosis. This led to the definition of a syndrome, acute-on-chronic liver failure (ACLF), marked by the severity of systemic inflammation, the development of organ failures and a high short-term mortality. The most common underlying liver etiology is related to acute alcohol hepatitis in western countries and to HBV or HCV cirrhosis in eastern countries. Twenty-eight and 90-days high mortality rates are well linked to the number of organ failure and defined, merely ten years ago, by a modified SOFA score. ACLF is a dynamic syndrome and grading can vary from hospital admission. ACLF grading between day 3-7 of admission is more accurate for determining outcome. ACLF-3 patients with ≥3 organ failures remain very challenging with >75% mortality rate. Despite recent advances in the medical management of critically ill cirrhotic patients, the prognosis of these patients remains poor. Currently, the main effective treatment is an urgent liver transplantation (LT) which is performed in a very selected patients eligible to transplant given the limited availability of organ donors and the low post-transplant survival rates reported in earlier studies. Recently, large retrospective multicenter studies and registries showed an improved 1-year post-transplant survival rate >83% in several transplant centers. Nevertheless, only few proportions of the ACLF-2 and ACLF-3 patients are transplanted representing 0-10% of most liver transplant programs. A careful selection of these patients (excluding major comorbidities i.e., older age, addictology criteria, severe malnutrition…) and optimal timing for transplant (infection control, hemodynamic stability, low oxygen and vasopressor requirements) are associated with excellent post-transplant survival rate.
发生失代偿事件且需要入住重症监护病房的肝硬化患者，其预后并不相同。这促使人们定义了一种综合征，即慢加急性肝衰竭（ACLF），其特征为全身炎症的严重程度、器官功能衰竭的发生以及较高的短期死亡率。在西方国家，最常见的潜在肝脏病因与急性酒精性肝炎有关，而在东方国家则与乙肝或丙肝肝硬化有关。28天和90天的高死亡率与器官衰竭的数量密切相关，并且在仅仅十年前，通过改良的序贯器官衰竭评估（SOFA）评分来定义。ACLF是一种动态综合征，其分级在入院时可能会有所不同。入院第3至7天的ACLF分级对于确定预后更为准确。伴有≥3个器官衰竭的ACLF-3患者仍然极具挑战性，死亡率超过75%。尽管在重症肝硬化患者的医疗管理方面最近取得了进展，但这些患者的预后仍然很差。目前，主要的有效治疗方法是紧急肝移植（LT），鉴于器官供体有限以及早期研究报道的移植后生存率较低，这种治疗仅在经过严格筛选且符合移植条件的患者中进行。最近，大型回顾性多中心研究和登记数据显示，在几个移植中心，移植后1年生存率提高至>83%。然而，只有很少一部分ACLF-2和ACLF-3患者能够接受移植，在大多数肝移植项目中仅占0-10%。对这些患者进行仔细筛选（排除主要合并症，即老年、成瘾标准、严重营养不良等）以及选择最佳移植时机（控制感染、血流动力学稳定、低氧和血管升压药需求）与优异的移植后生存率相关。
