慢加急性肝衰竭分型的临床价值与突破方向
DOI: 10.12449/JCH260801
利益冲突声明:本文不存在任何利益冲突。
作者贡献声明:徐曼曼负责设计论文框架,起草论文,修改论文;陈煜负责拟定写作思路,指导撰写文章并最后定稿。
Subtyping of acute-on-chronic liver failure: Clinical value and breakthrough directions
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摘要: 慢加急性肝衰竭(ACLF)是在慢性肝病基础上发生的急性失代偿综合征,具有病死率高、病情进展迅速、临床表型复杂及可逆窗口短暂等特征。当前,全球尚缺乏统一的ACLF标准化诊断体系,不同诊断标准在评估侧重点上存在显著差异,分别侧重于肝脏功能衰竭、肝外器官衰竭或特定病因背景下的高危状态。为实现ACLF患者的个体化风险分层、优化临床医疗资源配置,建立科学完善的精准分型体系已成为亟待解决的关键问题。传统静态化诊断模式仅局限于基线状态评估与死亡风险预测,无法反映疾病动态演化规律,亦难以有效区分不同患者对临床干预的应答差异。本文系统梳理了现阶段ACLF的主流定义与分型体系,分析各类分型框架在临床治疗决策、预后风险评估及临床试验方案设计中的应用价值与局限性;同时提出,ACLF临床分型体系需突破单一基线评估模式,向动态化、治疗导向化及跨病因一体化的整合评估模式转型,以期为人工肝支持治疗、重症监护管理、肝脏再生干预及肝移植手术指征判定等临床诊疗工作提供更为精准的理论依据。Abstract: Acute-on-chronic liver failure (ACLF) is an acute decompensation syndrome that develops on the background of chronic liver disease and is characterized by high mortality, rapid disease progression, complex clinical phenotypes, and a narrow window for reversibility. At present, there is still a lack of a unified standardized diagnostic system for ACLF globally, and there are significant differences between different diagnostic criteria in terms of liver failure, extrahepatic organ failure, and high-risk states within specific etiological contexts. To achieve individualized risk stratification of ACLF patients and optimize the allocation of clinical resources, it is urgently needed to establish a scientifically sound and precise classification system. Traditional static diagnostic models are confined only to baseline assessment and mortality prediction and fail to reflect dynamic disease evolution or effectively distinguish treatment response across different groups of patients. This article systematically reviews the major definitions and classification systems of ACLF at the current stage, analyzes the application value and limitations of various classification frameworks in clinical treatment decision-making, prognostic risk assessment, and clinical trial design, and proposes that the clinical classification system for ACLF should move beyond the single baseline evaluation approach toward a dynamic, treatment-oriented, and cross-etiology integrated assessment model, in order to provide a more precise theoretical basis for clinical diagnosis and treatment regarding artificial liver support, intensive care management, liver regeneration therapies, and determination of indications for liver transplantation.
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