Ghobrial R M, Steadman R, Gornbein J, Lassman C, Holt C D, Chen P, Farmer D G, Yersiz H, Danino N, Collisson E, Baquarizo A, Han S S, Saab S, Goldstein L I, Donovan J A, Esrason K, Busuttil R W
Dumont-UCLA Transplant Center, Department of Surgery, UCLA School of Medicine, Los Angeles, California 90095, USA.
Ann Surg. 2001 Sep;234(3):384-93; discussion 393-4. doi: 10.1097/00000658-200109000-00012.
To determine the factors affecting the outcome of orthotopic liver transplantation (OLT) for end-stage liver disease caused by hepatitis C virus (HCV) and to identify models that predict patient and graft survival.
The national epidemic of HCV infection has become the leading cause of hepatic failure that requires OLT. Rapidly increasing demands for OLT and depleted donor organ pools mandate appropriate selection of patients and donors. Such selection should be guided by a better understanding of the factors that influence the outcome of OLT.
The authors conducted a retrospective review of 510 patients who underwent OLT for HCV during the past decade. Seven donor, 10 recipient, and 2 operative variables that may affect outcome were dichotomized at the median for univariate screening. Factors that achieved a probability value less than 0.2 or that were thought to be relevant were entered into a stepdown Cox proportional hazard regression model.
Overall patient and graft survival rates at 1, 5, and 10 years were 84%, 68%, and 60% and 73%, 56%, and 49%, respectively. Overall median time to HCV recurrence was 34 months after transplantation. Neither HCV recurrence nor HCV-positive donor status significantly decreased patient and graft survival rates by Kaplan-Meier analysis. However, use of HCV-positive donors reduced the median time of recurrence to 22.9 months compared with 35.7 months after transplantation of HCV-negative livers. Stratification of patients into five subgroups, based on time of recurrence, revealed that early HCV recurrence was associated with significantly increased rates of patient death and graft loss. Donor, recipient, and operative variables that may affect OLT outcome were analyzed. On univariate analysis, recipient age, serum creatinine, donor length of hospital stay, donor female gender, United Network for Organ Sharing (UNOS) status of recipient, and presence of hepatocellular cancer affected the outcome of OLT. Elevation of pretransplant HCV RNA was associated with an increased risk of graft loss. Of 15 variables considered by multivariate Cox regression analysis, recipient age, UNOS status, donor gender, and log creatinine were simultaneous significant predictors for patient survival. Simultaneously significant factors for graft failure included log creatinine, log alanine transaminase, log aspartate transaminase, UNOS status, donor gender, and warm ischemia time. These variables were therefore entered into prognostic models for patient and graft survival.
The earlier the recurrence of HCV, the greater the impact on patient and graft survival. The use of HCV-positive donors may accelerate HCV recurrence, and they should be used judiciously. Patient survival at the time of transplantation is predicted by donor gender, UNOS status, serum creatinine, and recipient age. Graft survival is affected by donor gender, warm ischemia time, and pretransplant patient condition. The authors' current survival prognostic models require further multicenter validation.
确定影响丙型肝炎病毒（HCV）所致终末期肝病原位肝移植（OLT）结局的因素，并识别预测患者和移植物存活的模型。
全国范围内的HCV感染流行已成为需要OLT的肝衰竭的主要原因。对OLT的需求迅速增加以及供体器官库枯竭，要求对患者和供体进行适当选择。这种选择应以对影响OLT结局的因素的更好理解为指导。
作者对过去十年中接受HCV相关OLT的510例患者进行了回顾性研究。将可能影响结局的7个供体、10个受体和2个手术变量在中位数处进行二分法划分，用于单变量筛选。将概率值小于0.2或被认为相关的因素纳入逐步Cox比例风险回归模型。
患者和移植物的1年、5年和10年总体存活率分别为84%、68%和60%以及73%、56%和49%。移植后HCV复发的总体中位时间为34个月。通过Kaplan-Meier分析，HCV复发和HCV阳性供体状态均未显著降低患者和移植物存活率。然而，与移植HCV阴性肝脏后35.7个月相比，使用HCV阳性供体将复发的中位时间缩短至22.9个月。根据复发时间将患者分为五个亚组，结果显示早期HCV复发与患者死亡和移植物丢失率显著增加相关。分析了可能影响OLT结局的供体、受体和手术变量。单变量分析显示，受体年龄、血清肌酐、供体住院时间、供体女性性别、器官共享联合网络（UNOS）受体状态以及肝细胞癌的存在影响OLT结局。移植前HCV RNA升高与移植物丢失风险增加相关。在多变量Cox回归分析考虑的15个变量中，受体年龄、UNOS状态、供体性别和肌酐对数是患者存活的同时显著预测因素。移植物失败的同时显著因素包括肌酐对数、丙氨酸转氨酶对数、天冬氨酸转氨酶对数、UNOS状态、供体性别和热缺血时间。因此，将这些变量纳入患者和移植物存活的预后模型。
HCV复发越早，对患者和移植物存活的影响越大。使用HCV阳性供体可能会加速HCV复发，应谨慎使用。移植时的患者存活可通过供体性别、UNOS状态、血清肌酐和受体年龄来预测。移植物存活受供体性别、热缺血时间和移植前患者状况的影响。作者目前的存活预后模型需要进一步的多中心验证。
