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.

中文翻译：

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肝移植对慢加急性肝衰竭危重患者的益处：实施紧急活体供体计划


我们评估了慢加急性肝衰竭 （ACLF） 中的肝移植 （LT） 标准，纳入了紧急活体供体 LT （LDLT） 计划。纳入慢性肝衰竭联盟 （CLIF-C） ACLF 评分 （CLIF-C_ACLF_score） ≥65 分，以前被认为不适合 LT 的危重患者，以探索 CLIF-C_ACLF_score （CLIF-C_ACLF_score_threshold） 的超额死亡率阈值。在 2008 年至 2019 年期间，我们在 4432 名 LT 受者中连续随访了 854 名 ACLF 患者 （276 名 ACLF 2 级和 215 名 ACLF 3 级）。对于没有直接死亡供体 （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： >60% 1 年生存率和 >50% 5 年生存率。在预测 LT 后死亡率方面，CLIF-C_ACLF_score 优于 （终末期肝病模型-钠） MELD-Na 和 （终末期肝病模型） MELD-3.0 评分，但与 Sundaram ACLF-LT 死亡率评分相当。A CLIF-C_ACLF_score ≥65 （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 年死亡率的新型 CLIF-C_ACLF_score_threshold分别为 70 和 69。生成了基于 CLIF-C_ACLF_score 的列线图，用于预测生存概率，整合心血管疾病、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 不适合 LT 的标准。实施及时的挽救性 LT 策略，并结合紧急 LDLT，可以提高生存率。