Liver transplantation in acute liver failure: Dilemmas and challenges.
Liver transplantation in acute liver failure: Dilemmas and challenges.
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DOI：
10.5500/wjt.v11.i6.187
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发表时间：
2021-06-18
期刊：
影响因子：
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通讯作者：
Priyadarshi RN
中科院分区：
文献类型：
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作者：
Kumar R;Anand U;Priyadarshi RN
急性肝衰竭（ALF）是指在没有预先存在的肝病的情况下导致凝血和感觉改变的严重肝损伤状态。ALF有不同的原因，但临床特征惊人的相似。然而，在临床实践中，全球范围内ALF定义的不一致性以及对既存肝病存在的混淆引起了诊断难题。ALF死亡率过去曾超过80%;然而，由于对病理生理学的更深入了解和重症监护管理的进步，近年来药物治疗的存活率已显着提高。对乙酰氨基酚相关ALF的存活率已接近移植后存活率。鉴于肝移植（LT）是一种昂贵的治疗方法，涉及危重患者的大手术和终身免疫抑制，因此选择可能从中受益的准确患者非常重要。尽管如此，紧急LT仍然是许多ALF患者的救命手术。然而，目前的预后模型缺乏一致性，这阻碍了及时准确地选择移植候选人。在ALF中与LT相关的其他问题是移植物短缺，在等待名单上禁忌症的发展，模糊定义的除名标准，移植前评估的时间限制，伦理问题，以及ALF中相对较差的移植后结果。因此，迫切需要建立准确的预后模型，并探索不断发展的替代疗法和替代疗法的作用，如肝脏支持系统，血浆置换，干细胞，辅助LT等，以提高无移植存活率并填补移植物短缺造成的空白
Acute liver failure (ALF) refers to a state of severe hepatic injury that leads to altered coagulation and sensorium in the absence of pre-existing liver disease. ALF has different causes, but the clinical characteristics are strikingly similar. In clinical practice, however, inconsistency in the definition of ALF worldwide and confusion regarding the existence of pre-existing liver disease raise diagnostic dilemmas. ALF mortality rates used to be over 80% in the past; however, survival rates on medical treatment have significantly improved in recent years due to a greater understanding of pathophysiology and advances in critical care management. The survival rates in acetaminophen-associated ALF have become close to the post-transplant survival rates. Given that liver transplantation (LT) is an expensive treatment that involves a major surgical operation in critically ill patients and lifelong immunosuppression, it is very important to select accurate patients who may benefit from it. Still, emergency LT remains a lifesaving procedure for many ALF patients. However, there is a lack of consistency in current prognostic models that hampers the selection of transplant candidates in a timely and precise manner. The other problems associated with LT in ALF are the shortage of graft, development of contraindications on the waiting list, vaguely defined delisting criteria, time constraints for pre-transplant evaluation, ethical concerns, and comparatively poor post-transplant outcomes in ALF. Therefore, there is a desperate need to establish accurate prognostic models and explore the roles of evolving adjunctive and alternative therapies, such as liver support systems, plasma exchange, stem cells, auxiliary LT, and so on, to enhance transplant-free survival and to fill the void created by the graft shortage