Kwon Hye-Mee, Kim Jae Hwan, Kim Sung-Hoon, Jun In-Gu, Song Jun-Gol, Moon Deok-Bog, Hwang Gyu-Sam
Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Am J Transplant. 2025 Jan;25(1):150-163. doi: 10.1016/j.ajt.2024.08.008. Epub 2024 Aug 21.
We evaluated the liver transplantation (LT) criteria in acute-on-chronic liver failure (ACLF), incorporating an urgent living-donor LT (LDLT) program. Critically ill patients with a Chronic Liver Failure Consortium (CLIF-C) ACLF score (CLIF-C_ACLF_score) ≥65, previously considered unsuitable for LT, were included to explore the excess mortality threshold of the CLIF-C_ACLF_score (CLIF-C_ACLF_score_threshold). We followed 854 consecutive patients with ACLF (276 ACLF grade 2 and 215 ACLF grade 3) over 10 years among 4432 LT recipients between 2008 and 2019. For advanced ACLF patients without immediate deceased-donor (DD) allocation, an urgent LDLT program was expedited. The CLIF-C_ACLF_score_threshold was determined by the metrics of transplant survival benefit: >60% 1-year and >50% 5-year survival rate. In predicting post-LT mortality, the CLIF-C_ACLF_score outperformed the (model for end-stage liver disease-sodium) MELD-Na and (model for end-stage liver disease) MELD-3.0 scores but was comparable to the Sundaram ACLF-LT-mortality score. A CLIF-C_ACLF_score ≥65 (n = 54) demonstrated posttransplant survival benefits, with 1-year and 5-year survival rates of 66.7% and 50.4% (P < .001), respectively. Novel CLIF-C_ACLF_score_threshold for 1-year and 5-year mortalities was 70 and 69, respectively. A CLIF-C_ACLF_score-based nomogram for predicting survival probabilities, integrating cardiovascular disease, diabetes, and donor type (LDLT vs DDLT), was generated. This study suggests reconsidering the criteria for unsuitable LT with a CLIF-C_ACLF_score ≥65. Implementing a timely salvage LT strategy, and incorporating urgent LDLT, can enhance survival rates.
我们评估了急性慢性肝衰竭（ACLF）中的肝移植（LT）标准，并纳入了紧急活体供肝肝移植（LDLT）计划。纳入慢性肝衰竭联盟（CLIF-C）ACLF评分（CLIF-C_ACLF_score）≥65分、之前被认为不适合进行肝移植的重症患者，以探索CLIF-C_ACLF_score的过高死亡率阈值（CLIF-C_ACLF_score_threshold）。在2008年至2019年间的4432例肝移植受者中，我们对854例连续的ACLF患者（276例ACLF 2级和215例ACLF 3级）进行了为期10年的随访。对于没有立即获得尸体供肝（DD）分配的晚期ACLF患者，加快了紧急LDLT计划。CLIF-C_ACLF_score_threshold由移植生存获益指标确定：1年生存率>60%，5年生存率>50%。在预测肝移植后死亡率方面，CLIF-C_ACLF_score优于终末期肝病-钠（MELD-Na）模型和终末期肝病（MELD-3.0）评分，但与Sundaram ACLF-LT-死亡率评分相当。CLIF-C_ACLF_score≥65分（n = 54）显示出移植后生存获益，1年和5年生存率分别为66.7%和50.4%（P <.001）。1年和5年死亡率的新CLIF-C_ACLF_score_threshold分别为70和69。生成了一个基于CLIF-C_ACLF_score的列线图，用于预测生存概率，纳入了心血管疾病、糖尿病和供体类型（LDLT与DDLT）。本研究建议重新考虑CLIF-C_ACLF_score≥65分的不适合肝移植的标准。实施及时的挽救性肝移植策略，并纳入紧急LDLT，可以提高生存率。
