慢加急性肝衰竭肝移植评估决策的演进、融合与挑战

武羽; 徐曼曼; 陈煜

doi:10.12449/JCH260307

慢加急性肝衰竭肝移植评估决策的演进、融合与挑战

DOI: 10.12449/JCH260307

首都医科大学附属北京佑安医院肝病中心四科，北京 100069

基金项目:

首都卫生发展科研专项 (2024-1-2181);

北京市医院管理中心“登峰”计划专项 (DFL20221501);

新发突发与重大传染病防控国家科技重大专项 (2025ZD01906501)

利益冲突声明：本文不存在任何利益冲突。

作者贡献声明：武羽负责文献检索，初稿撰写及修改；徐曼曼负责论文修改；陈煜负责拟定写作思路，指导论文撰写并修改论文。

详细信息

通信作者:
陈煜， chybeyond1071@ccmu.edu.cn （ORCID： 0000-0003-1906-7486）

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出版历程
- 收稿日期: 2025-12-16
- 录用日期: 2026-01-22
- 出版日期: 2026-03-25

Evaluation and decision-making for liver transplantation in acute-on-chronic liver failure： Evolution， integration， and challenges

Fourth Department of Liver Disease Center，Beijing YouAn Hospital，Capital Medical University，Beijing 100069，China

Research funding:

Capital’s Funds for the Health Improvement and Research (2024-1-2181);

Beijing Hospitals Authority’s Ascent Plan (DFL20221501);

Prevention and Control of Emerging and Major Infectious Diseases-National Science and Technology Major Project (2025ZD01906501)

More Information

Corresponding author: CHEN Yu， chybeyond1071@ccmu.edu.cn （ORCID： 0000-0003-1906-7486）

摘要

摘要: 慢加急性肝衰竭是在慢性肝病基础上出现的急性肝功能失代偿综合征，短期病死率高，肝移植是确切有效的根治性手段，可显著提高生存率。然而，在全球性器官短缺的背景下，如何在拯救生命与避免无效移植并优化器官利用之间取得平衡，是临床决策的关键。本文系统梳理了慢加急性肝衰竭患者肝移植评估决策体系的演进，指出其核心已从依赖单一的终末期肝病模型评分，转变为基于多维度预后模型、动态评估和多学科协作的模式。未来，融合东西方标准、利用人工智能精准预测以及建立更公平的优先分配系统，将是该领域发展的关键方向。
- 慢加急性肝功能衰竭 /
- 肝移植 /
- 危险性评估
Abstract: Acute-on-chronic liver failure （ACLF） is a syndrome of acute liver function decompensation in patients with chronic liver disease and is characterized by a high short-term mortality rate. Liver transplantation is an effective radical treatment method for ACLF and can significantly improve the survival rate of patients. However， in the context of a shortage of donor organs globally， how to achieve a balance between saving lives and avoiding futile transplantation while optimizing organ utilization is a critical challenge in clinical decision-making. This article systematically reviews the evolution of the evaluation and decision-making system for liver transplantation in ACLF patients and points out s that the core of this system has shifted from relying solely on the MELD score to a model based on multidimensional prognostic assessment， dynamic evaluation， and multidisciplinary collaboration. In the future， the integration of Eastern and Western criteria， the application of artificial intelligence for precise prediction， and the establishment of a more equitable priority and allocation system will be the key directions for development in this field.
- Acute-On-Chronic Liver Failure /
- Liver Transplantation /
- Risk Assessment

HTML全文

注： ACLF，慢加急性肝衰竭；MELD-Na，终末期肝病模型联合血清钠；COSSH-ACLF Ⅱ，中国重型乙型肝炎研究小组慢加急性肝衰竭2.0版；CLIF-C ACLF，慢性肝衰竭联盟-慢加急性肝衰竭；TAM，ACLF 3级患者肝移植模型；HALT，乙型肝炎病毒相关慢加急性肝衰竭肝移植模型；SALT-M，Sundaram ACLF肝移植死亡率。

图 1 ACLF患者肝移植决策体系图

Figure 1. Liver transplant decision-making system for ACLF patients

下载: 全尺寸图片幻灯片

参考文献(37)

[1]	Severe LiverDisease and Artificial Liver Group, Chinese Society of Hepatology, Chinese Medical Association; Nutrition and Regeneration in End-Stage Liver Disease Group, Chinese Society of Hepatology, Chinese Medical Association. Guidelines for the diagnosis and treatment of acute-on-chronic liver failure(2025 version)[J]. J Prac Hepatol, 2025, 28( 5): 641- 647. DOI: 10.3969/j.issn.1672-5069.2025.05.001. 中华医学会肝病学分会重型肝病与人工肝学组, 中华医学会肝病学分会终末期肝病营养与再生学组. 慢加急性肝衰竭诊治指南(2025年版)[J]. 实用肝脏病杂志, 2025, 28( 5): 641- 647. DOI: 10.3969/j.issn.1672-5069.2025.05.001.
[2]	XU MM, ZOU HB, DUAN ZP, et al. Interpretation of guideline for diagnosis and treatment of acute-on-chronic liver failure(2025 edition)[J]. J Clin Hepatol, 2025, 41( 5): 844- 850. DOI: 10.12449/JCH250508. 徐曼曼, 邹怀宾, 段钟平, 等.《慢加急性肝衰竭诊治指南(2025年版)》解读[J]. 临床肝胆病杂志, 2025, 41( 5): 844- 850. DOI: 10.12449/JCH250508.
[3]	TREBICKA J, PRAKTIKNJO M, PEIFFER KH, et al. Acute-on-chronic liver failure[J]. Dtsch Arztebl Int, 2025, 122( 4): 96- 102. DOI: 10.3238/arztebl.m2024.0255.
[4]	WU Y, XU MM, DUAN BW, et al. Acute-on-chronic liver failure: Clinical course and liver transplantation[J]. Expert Rev Gastroenterol Hepatol, 2023, 17( 3): 251- 262. DOI: 10.1080/17474124.2023.2180630.
[5]	LAI M, XU MM, WANG X, et al. Prognostic evaluation of liver transplantation for acute-on-chronic liver failure[J]. Ogran Transplant, 2025, 16( 3): 482- 488. DOI: 10.12464/j.issn.1674-7445.2025002. 赖曼, 徐曼曼, 王鑫, 等. 慢加急性肝衰竭肝移植预后评估[J]. 器官移植, 2025, 16( 3): 482- 488. DOI: 10.12464/j.issn.1674-7445.2025002.
[6]	KAMATH PS, WIESNER RH, MALINCHOC M, et al. A model to predict survival in patients with end-stage liver disease[J]. Hepatology, 2001, 33( 2): 464- 470. DOI: 10.1053/jhep.2001.22172.
[7]	BERNARDI M, GITTO S, BISELLI M. The MELD score in patients awaiting liver transplant: Strengths and weaknesses[J]. J Hepatol, 2011, 54( 6): 1297- 1306. DOI: 10.1016/j.jhep.2010.11.008.
[8]	HERNAEZ R, LIU Y, KRAMER JR, et al. Model for end-stage liver disease-sodium underestimates 90-day mortality risk in patients with acute-on-chronic liver failure[J]. J Hepatol, 2020, 73( 6): 1425- 1433. DOI: 10.1016/j.jhep.2020.06.005.
[9]	JALAN R, GUSTOT T, FERNANDEZ J, et al.‘Equity’ and‘Justice’ for patients with acute-on chronic liver failure: A call to action[J]. J Hepatol, 2021, 75( 5): 1228- 1235. DOI: 10.1016/j.jhep.2021.06.017.
[10]	SUNDARAM V, JALAN R, WU T, et al. Factors associated with survival of patients with severe acute-on-chronic liver failure before and after liver transplantation[J]. Gastroenterology, 2019, 156( 5): 1381- 1391. DOI: 10.1053/j.gastro.2018.12.007.
[11]	European Association for the Study of the Liver. EASL clinical practice guidelines on acute-on-chronic liver failure[J]. J Hepatol, 2023, 79( 2): 461- 491. DOI: 10.1016/j.jhep.2023.04.021.
[12]	BERNAL W, TAYLOR R, ROWE IA, et al. Liver transplantation for critically ill patients with acute on chronic liver failure: A prospective national programme of waitlist prioritisation[J]. Lancet Reg Health Eur, 2024, 46: 101067. DOI: 10.1016/j.lanepe.2024.101067.
[13]	ARTRU F, SACLEUX SC, URSIC-BEDOYA J, et al. Long-term outcome following liver transplantation of patients with ACLF grade 3[J]. J Hepatol, 2025, 82( 1): 62- 71. DOI: 10.1016/j.jhep.2024.06.039.
[14]	National Health Commission of the People’s Republic of China. Circular of Issuing Basic Principles and Core Policies for the Distribution and Sharing of Human Organs of China[J]. Gazette of the National Health Commission of the People’s Republic of China, 2018( 7): 11- 24. 国家卫生健康委员会. 关于印发中国人体器官分配与共享基本原则和核心政策的通知[J]. 中华人民共和国国家卫生和计划生育委员会公报, 2018( 7): 11- 24.
[15]	WANG JY, LI CY, XU HQ, et al. The development of the definition of acute-on-chronic liver failure and the differences between East and West[J]. Chin J Gastroenterol Hepatol, 2025, 34( 9): 1378- 1383. DOI: 10.3969/j.issn.1006-5709.2025.09.024. 王佳颖, 李春燕, 徐华谦, 等. 慢加急性肝衰竭定义的发展及东西方差异研究进展[J]. 胃肠病学和肝病学杂志, 2025, 34( 9): 1378- 1383. DOI: 10.3969/j.issn.1006-5709.2025.09.024.
[16]	HERNAEZ R, LI H, MOREAU R, et al. Definition, diagnosis and epidemiology of acute-on-chronic liver failure[J]. Liver Int, 2025, 45( 3): e15670. DOI: 10.1111/liv.15670.
[17]	CHOUDHURY A, KULKARNI AV, ARORA V, et al. Acute-on-chronic liver failure(ACLF): The‘Kyoto Consensus’-steps from Asia[J]. Hepatol Int, 2025, 19( 1): 1- 69. DOI: 10.1007/s12072-024-10773-4.
[18]	SACLEUX SC, ICHAÏ P, COILLY A, et al. Liver transplant selection criteria and outcomes in critically ill patients with ACLF[J]. JHEP Rep, 2024, 6( 1): 100929. DOI: 10.1016/j.jhepr.2023.100929.
[19]	SUNDARAM V, KOGACHI S, WONG RJ, et al. Effect of the clinical course of acute-on-chronic liver failure prior to liver transplantation on post-transplant survival[J]. J Hepatol, 2020, 72( 3): 481- 488. DOI: 10.1016/j.jhep.2019.10.013.
[20]	LI P, LIANG X, LUO JJ, et al. Predicting the survival benefit of liver transplantation in HBV-related acute-on-chronic liver failure: An observational cohort study[J]. Lancet Reg Health West Pac, 2022, 32: 100638. DOI: 10.1016/j.lanwpc.2022.100638.
[21]	XU MM, WU Y, LI SS, et al. Application of different prognostic scores in liver transplantation decision-making for acute-on-chronic liver failure[J]. Chin J Hepatol, 2023, 31( 6): 574- 581. DOI: 10.3760/cma.j.cn501113-20230202-00031. 徐曼曼, 武羽, 李珊珊, 等. 不同预后评分在慢加急性肝衰竭肝移植决策中的应用[J]. 中华肝脏病杂志, 2023, 31( 6): 574- 581. DOI: 10.3760/cma.j.cn501113-20230202-00031.
[22]	XIA L, QIAO ZY, ZHANG ZJ, et al. Transplantation for EASL-CLIF and APASL acute-on-chronic liver failure(ACLF) patients: The TEA cohort to evaluate long-term post-Transplant outcomes[J]. EClinicalMedicine, 2022, 49: 101476. DOI: 10.1016/j.eclinm.2022.101476.
[23]	MICHARD B, ARTZNER T, LEBAS B, et al. Liver transplantation in critically ill patients: Preoperative predictive factors of post-transplant mortality to avoid futility[J]. Clin Transplant, 2017, 31( 12): e13115. DOI: 10.1111/ctr.13115.
[24]	BELLI LS, DUVOUX C, ARTZNER T, et al. Liver transplantation for patients with acute-on-chronic liver failure(ACLF) in Europe: Results of the ELITA/EF-CLIF collaborative study(ECLIS)[J]. J Hepatol, 2021, 75( 3): 610- 622. DOI: 10.1016/j.jhep.2021.03.030.
[25]	KIM JE, SINN DH, CHOI GS, et al. Predictors and outcome of emergent Liver transplantation for patients with acute-on-chronic liver failure[J]. Dig Liver Dis, 2021, 53( 8): 1004- 1010. DOI: 10.1016/j.dld.2021.03.030.
[26]	LEVESQUE E, WINTER A, NOORAH Z, et al. Impact of acute-on-chronic liver failure on 90-day mortality following a first liver transplantation[J]. Liver Int, 2017, 37( 5): 684- 693. DOI: 10.1111/liv.13355.
[27]	ARTZNER T, MICHARD B, WEISS E, et al. Liver transplantation for critically ill cirrhotic patients: Stratifying utility based on pretransplant factors[J]. Am J Transplant, 2020, 20( 9): 2437- 2448. DOI: 10.1111/ajt.15852.
[28]	HERNAEZ R, KARVELLAS CJ, LIU Y, et al. The novel SALT-M score predicts 1-year post-transplant mortality in patients with severe acute-on-chronic liver failure[J]. J Hepatol, 2023, 79( 3): 717- 727. DOI: 10.1016/j.jhep.2023.05.028.
[29]	KIM K, YIM SH, LEE JG, et al. Robust predictive performance of the SALT-M score for clinical outcomes in Asian patients with acute-on-chronic liver failure[J]. Aliment Pharmacol Ther, 2025, 61( 1): 168- 176. DOI: 10.1111/apt.18335.
[30]	ZHUANG L, LIN YM, JIA Y, et al. Development and validation of a novel prognostic model to predict 1-year post-transplant mortality for acute-on-chronic hepatitis B liver failure: A nationwide, multicentre, cohort study[J]. EClinicalMedicine, 2025, 86: 103365. DOI: 10.1016/j.eclinm.2025.103365.
[31]	CHEAH YL, SIMPSON MA, POMPOSELLI JJ, et al. Incidence of death and potentially life-threatening near-miss events in living donor hepatic lobectomy: A world-wide survey[J]. Liver Transpl, 2013, 19( 5): 499- 506. DOI: 10.1002/lt.23575.
[32]	ZHANG S, SUEN SC, GONG CL, et al. Early transplantation maximizes survival in severe acute-on-chronic liver failure: Results of a Markov decision process model[J]. JHEP Rep, 2021, 3( 6): 100367. DOI: 10.1016/j.jhepr.2021.100367.
[33]	HOU YX, ZHANG QQ, GAO FY, et al. Artificial neural network-based models used for predicting 28- and 90-day mortality of patients with hepatitis B-associated acute-on-chronic liver failure[J]. BMC Gastroenterol, 2020, 20( 1): 75. DOI: 10.1186/s12876-020-01191-5.
[34]	SHI KQ, ZHOU YY, YAN HD, et al. Classification and regression tree analysis of acute-on-chronic hepatitis B liver failure: Seeing the forest for the trees[J]. J Viral Hepat, 2017, 24( 2): 132- 140. DOI: 10.1111/jvh.12617.
[35]	VERMA N, CHOUDHURY A, SINGH V, et al. APASL-ACLF Research Consortium-Artificial Intelligence(AARC-AI) model precisely predicts outcomes in acute-on-chronic liver failure patients[J]. Liver Int, 2023, 43( 2): 442- 451. DOI: 10.1111/liv.15361.
[36]	YEO YH, ZHANG MY, MCCOY MS, et al. Predictive machine learning model in intensive care unit patients with acute-on-chronic liver failure and two or more organ failures[J]. Clin Mol Hepatol, 2025, 31( 4): 1355- 1371. DOI: 10.3350/cmh.2025.0573.
[37]	JIANG W, CHANG XJ, ZENG F, et al. Current status of research on artificial intelligence in prognostic prediction models for acute-on-chronic liver failure[J]. J Clin Hepatol, 2024, 40( 9): 1891- 1896. DOI: 10.12449/JCH240927. 姜伟, 常秀君, 曾帆, 等. 人工智能在慢加急性肝衰竭预后预测模型中的研究现状[J]. 临床肝胆病杂志, 2024, 40( 9): 1891- 1896. DOI: 10.12449/JCH240927.