In this debate, the authors consider whether patients with acute-on-chronic liver failure grade 3 (ACLF-3) should receive higher liver transplant priority, with reference to the following clinical case: a 62-year-old male with a history of decompensated alcohol-associated cirrhosis, with recurrent ascites and hepatic encephalopathy, and metabolic comorbidities (type 2 diabetes mellitus, arterial hypertension and a BMI of 31 kg/m²). A few days following evaluation for liver transplantation (LT), the patient was admitted to the intensive care unit and placed on mechanical ventilation for neurological failure, FiO₂ of 0.3 with a SpO₂ of 98%, and started on norepinephrine at 0.62 μg/kg/min. He had been abstinent since the diagnosis of cirrhosis a year prior. Laboratory results at admission were: leukocyte count 12.1 G/L, international normalised ratio 2.1, creatinine 2.4 mg/dl, sodium 133 mmol/L, total bilirubin 7 mg/dl, lactate 5.5 mmol/L, with a MELD-Na score of 31 and a CLIF-C ACLF score of 67. On the 7^th day after admission, the patient was placed on the LT waiting list. On the same day, he had massive variceal bleed with hypovolemic shock requiring terlipressin, transfusion of three red blood cell units, and endoscopic band ligation. On day 10, the patient was stabilised with a low dose of norepinephrine 0.03 μg/kg/min, with no new sepsis or bleeding. However, the patient was still intubated for grade 2 hepatic encephalopathy and on renal replacement therapy with a lactate level of 3.1 mmol/L. The patient is currently categorised as having ACLF-3, with five organ failures (liver, kidney, coagulation, circulation, and respiration). Based on the severity of his liver disease and multiorgan failure, the patient is at an exceedingly high risk of death without LT. Is it appropriate to perform LT in such a patient?

在这场争论中，作者参考以下临床病例，考虑慢加急性肝衰竭3级（ACLF-3）患者是否应该接受更高的肝移植优先级：一名62岁男性，有肝移植史失代偿性酒精相关性肝硬化，伴有复发性腹水和肝性脑病，以及代谢合并症（2 型糖尿病、动脉高血压和 BMI 31 kg/m 2 ^）。肝移植 (LT) 评估几天后，患者被送入重症监护室并因神经功能衰竭接受机械通气，FiO ₂为 0.3，SpO ₂98%，并开始以 0.62 μg/kg/min 的剂量服用去甲肾上腺素。自从一年前诊断出肝硬化以来，他就一直禁欲。入院时的实验室结果为：白细胞计数 12.1 G/L，国际标准化比值 2.1，肌酐 2.4 mg/dl，钠 133 mmol/L，总胆红素 7 mg/dl，乳酸 5.5 mmol/L，MELD-Na 评分为31 分，CLIF-C ACLF 分数为 67。7^日入院后第二天，患者被列入 LT 等候名单。同一天，他出现静脉曲张大出血并伴有低血容量性休克，需要特利加压素、输注三个红细胞单位并进行内镜套扎术。第10天，患者通过低剂量去甲肾上腺素0.03μg/kg/min病情稳定，没有出现新的脓毒症或出血。然而，患者仍因 2 级肝性脑病插管并接受肾脏替代治疗，乳酸水平为 3.1 mmol/L。该患者目前被归类为 ACLF-3，有 5 个器官衰竭（肝、肾、凝血、循环和呼吸）。根据其肝病和多器官衰竭的严重程度，如果不进行 LT，该患者的死亡风险极高。对于这样的患者进行 LT 合适吗？