BACKGROUND & AIMS Liver transplantation (LT) for the most severely ill patients with cirrhosis, with multiple organ dysfunction (accurately assessed by the acute-on-chronic liver failure [ACLF] classification) remains controversial. We aimed to report the results of LT in patients with ACLF grade 3 and to compare these patients to non-transplanted patients with cirrhosis and multiple organ dysfunction as well as to patients transplanted with lower ACLF grade. METHODS All patients with ACLF-3 transplanted in three liver intensive care units (ICUs) were retrospectively included. Each patient with ACLF-3 was matched to a) non-transplanted patients hospitalized in the ICU with multiple organ dysfunction, or b) control patients transplanted with each of the lower ACLF grades (three groups). RESULTS Seventy-three patients were included. These severely ill patients were transplanted following management to stabilize their condition with a median of nine days after admission (progression of mean organ failure from 4.03 to 3.67, p=0.009). One-year survival of transplanted patients with ACLF-3 was higher than that of non-transplanted controls: 83.9 vs. 7.9%, p<0.0001. This high survival rate was not different from that of matched control patients with no ACLF (90%), ACLF-1 (82.3%) or ACLF-2 (86.2%). However, a higher rate of complications was observed (100 vs. 51.2 vs. 76.5 vs. 74.3%, respectively), with a longer hospital stay. The notion of a "transplantation window" is discussed. CONCLUSIONS LT strongly influences the survival of patients with cirrhosis and ACLF-3 with a 1-year survival similar to that of patients with a lower grade of ACLF. A rapid decision-making process is needed because of the short "transplantation window" suggesting that patients with ACLF-3 should be rapidly referred to a specific liver ICU. Lay summary: Liver transplantation improves survival of patients with very severe cirrhosis. These patients must be carefully monitored and managed in a specialized unit. The decision to transplant a patient must be quick to avoid a high risk of mortality.

中文翻译：

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最严重肝硬化患者的肝移植：急性-慢性肝功能衰竭 3 级的多中心研究

背景和目的 肝移植 (LT) 用于最严重的肝硬化患者，并伴有多器官功能障碍（通过急性-慢性肝功能衰竭 [ACLF] 分类准确评估）仍然存在争议。我们旨在报告 ACLF 3 级患者 LT 的结果，并将这些患者与肝硬化和多器官功能障碍的非移植患者以及 ACLF 等级较低的移植患者进行比较。方法回顾性纳入三个肝脏重症监护病房（ICU）移植的ACLF-3患者。每个 ACLF-3 患者都与 a) ICU 住院的多器官功能障碍的非移植患者相匹配，或 b) 移植了每个较低 ACLF 等级的对照患者（三组）。结果 包括 73 名患者。这些重症患者在接受治疗后接受移植以稳定他们的病情，入院后中位数为 9 天（平均器官衰竭从 4.03 进展到 3.67，p=0.009）。ACLF-3 移植患者的一年生存率高于非移植对照组：83.9 与 7.9%，p<0.0001。这种高存活率与没有 ACLF (90%)、ACLF-1 (82.3%) 或 ACLF-2 (86.2%) 的匹配对照患者没有区别。然而，观察到更高的并发症发生率（分别为 100% vs. 51.2% vs. 76.5% vs. 74.3%），住院时间更长。讨论了“移植窗口”的概念。结论 LT 强烈影响肝硬化和 ACLF-3 患者的生存率，其 1 年生存率与较低级别 ACLF 患者的生存率相似。由于较短的“移植窗口”表明 ACLF-3 患者应迅速转诊至特定的肝脏 ICU，因此需要一个快速的决策过程。总结：肝移植可提高非常严重肝硬化患者的生存率。这些患者必须在专门的单位进行仔细监测和管理。必须迅速做出移植患者的决定，以避免高死亡风险。