探究慢加急性肝衰竭(ACLF)患者肝移植等待期降级治疗对其预后的影响。

回顾性分析2018年1月至2024年8月在上海交通大学医学院附属仁济医院肝脏外科肝移植等待名单中的344例ACLF患者临床资料，其中移植组242例，未移植组102例。依据中国重症乙型肝炎协作组-ACLF指南中的标准将ACLF划分为1~3级。移植组以行肝移植前末次检查时间点为评分结局时间；未移植组以出院前末次检查指标或死亡前末次检查指标为评分结局时间。在评定ACLF等级变化基础上融入"器官衰竭＋器官损伤"的评价方法，根据降级治疗是否成功，将患者分为降级成功组与降级失败组。呈正态分布计量资料组间比较采用独立样本t检验；不符合正态分布计量资料组间比较采用Mann-Whitney U检验。计数资料组间比较采用卡方检验。采用Kaplan-Meier法绘制患者生存曲线，并采用log-rank检验进行比较。P<0.05为差异有统计学意义。

移植组和未移植组γ-谷氨酰转移酶、血清葡萄糖、凝血酶原时间、血清肌酐、发生肾功能衰竭的比例、国际标准化比值、发生凝血功能衰竭的比例和终末期肝病模型评分差异均有统计学意义(Z/χ²＝－2.315、－2.260、－4.299、－2.434、4.428、－5.263、13.021和－5.282，P均<0.05)。结局事件发生时225例患者降级治疗成功(降级成功组)，其中移植组和未移植组分别有193和32例；119例降级治疗失败(降级失败组)，其中移植组和未移植组分别有49和70例。降级成功组(n＝225)ACLF患者1年累积生存率高于降级失败组(n＝119)(χ²＝81.95，P<0.05)；进一步分析发现，未移植组中降级成功ACLF患者(n＝32)1年累积生存率高于降级失败者(n＝70)(χ²＝4.28，P<0.05)；移植组中降级成功ACLF患者(n＝193)1年累积生存率与降级失败者(n＝49)差异无统计学意义(χ²＝2.62，P>0.05)。

降级治疗可提高ACLF患者短期预后以及未接受肝移植患者生存率，延长肝移植等待期。

To investigate the impact of downgrading therapy during liver transplant waiting period on the prognosis of patients with acute-on-chronic liver failure (ACLF).

A retrospective analysis was performed on 344 ACLF patients who were on the liver transplantation waiting list at the Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, from January 2018 to August 2024. The cohort included 102 patients who did not undergo transplantation and 242 patients who completed liver transplantation. Based on the Chinese Group on the Study of Severe Hepatitis B-ACLF guideline, ACLF was classified into grades 1 to 3. For the transplant group, the last examination prior to liver transplantation was used as the endpoint for scoring, while for the non-transplant group, the last examination before discharge or prior to death was used as the scoring endpoint. In addition to assessing changes in ACLF grades, an evaluation method based on "organ failure + organ injury" was incorporated. After downgrading therapy, patients were divided into a successful downgrading group and a failed downgrading group. Normally distributed continuous variables were compared using the independent-samples t-test; non-normally distributed continuous variables were compared using the Mann-Whitney U test. Categorical variables were compared using the chi-square test. Kaplan-Meier survival curves were constructed, and comparisons were made using the log-rank test. A P-value of <0.05 was considered statistically significant.

The differences in γ-glutamyltransferase, serum glucose, prothrombin time, serum creatinine, the proportion of patients with renal failure, international normalized ratio, the proportion of patients with coagulopathy, and the model for end-stage liver disease score between the transplant and non-transplant groups were statistically significant (Z/χ²=-2.315, -2.260, -4.299, -2.434, 4.428, -5.263, 13.021, and -5.282, all P<0.05). At the time of outcome events, 225 patients achieved successful downgrading therapy (successful downgrading group), including 193 in the transplant group and 32 in the non-transplant group. A total of 119 patients experienced failure of downgrading therapy (failed downgrading group), including 49 cases in the transplant group and 70 cases in the non-transplant group. The 1-year cumulative survival rate of ACLF patients in the successful downgrading group (n=225) was higher than that in the failed downgrading group (n=119) (χ²=81.95, P<0.05). Further analysis showed that in the non-transplant group, the 1-year cumulative survival rate of ACLF patients in the successful downgrading group (n=32) was higher than that in the failed downgrading group (n=70) (χ²=4.28, P<0.05). However, in the transplant group, there was no statistically significant difference in the 1-year cumulative survival rate between the successful downgrading group (n=193) and the failed downgrading group (n=49) (χ²=2.62, P>0.05).

Successful downgrading can improve the overall short-term prognosis of all patients with ACLF and the survival rate of non-transplanted patients, and extend the liver transplant waiting period.