Martí Josep, Charco Ramón, Ferrer Joana, Calatayud David, Rimola Antoni, Navasa Miquel, Fondevila Constantino, Fuster Josep, García-Valdecasas Juan Carlos
Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabolisme, Hospital Clínic i Provincial, CIBERehd, Barcelona, Spain.
Surgery. 2008 Nov;144(5):762-9. doi: 10.1016/j.surg.2008.06.029. Epub 2008 Sep 3.
Liver retransplantation (ReLT) is the only therapeutic option that offers a chance at long-term survival when a liver graft fails. Careful analysis of the results and potential benefits is needed to justify its role in the current era of donor shortage and economical concerns. We reviewed all retransplants performed in our hospital and tried to determine if there is a high risk group of patients in whom its use would be contraindicated.
Between June 1988 and January 2006, 1,226 liver transplants were performed in 1,118 patients at our institution. Among them, 108 retransplants (8.8%) were performed in 98 patients. Preoperative, intraoperative, and postoperative data were gathered from our prospectively collected liver transplant database. The entire series of patients was divided between two periods of equal duration and patients were also classified according to the interval between retransplantation and the previous transplant.
Concerning indications, only chronic rejection was a more frequent etiology in the first period versus the second period. When comparing first and second periods, 1-, 5-, and 10-year graft survival was 66%, 45%, and 40% and 76%, 69%, and 69%, respectively (P = .014). No significant differences in post-ReLT survival were found when the indication was HCV recurrence versus other non-urgent causes (1-, 5-, and 10-year graft survival: 70%, 57%, and 57% vs 72%, 50%, and 45%). According to the UNOS Rosen risk score, patients in the low-risk group showed significantly greater survival with respect to patients in the high-risk group though 5-year survival in the high-risk group was still greater than 50%.
ReLT indications have changed over time, with better results being achieved in more recent years. Candidate selection in elective ReLT is critical to improve the results, though current criteria do not allow for the identification of a single patient subset in which ReLT would be contraindicated.
当肝移植失败时，再次肝移植（ReLT）是提供长期生存机会的唯一治疗选择。在当前供体短缺和经济问题的时代，需要仔细分析结果和潜在益处，以证明其作用。我们回顾了我院进行的所有再次移植，并试图确定是否存在使用再次肝移植会被禁忌的高危患者群体。
1988年6月至2006年1月期间，我院对1118例患者进行了1226例肝移植。其中，98例患者进行了108次再次移植（8.8%）。术前、术中和术后数据均来自我们前瞻性收集的肝移植数据库。将整个患者系列分为两个等长的时期，患者也根据再次移植与前一次移植之间的间隔进行分类。
关于适应证，与第二个时期相比，仅慢性排斥在第一个时期是更常见的病因。比较第一个和第二个时期，1年、5年和10年移植存活率分别为66%、45%和40%以及76%、69%和69%（P = 0.014）。当适应证为丙型肝炎病毒复发与其他非紧急原因时，再次肝移植后生存无显著差异（1年、5年和10年移植存活率：70%、57%和57%对72%、50%和45%）。根据美国器官共享联合网络（UNOS）罗森风险评分，低风险组患者的生存率明显高于高风险组患者，尽管高风险组的5年生存率仍大于50%。
再次肝移植的适应证随时间发生了变化，近年来取得了更好的结果。在选择性再次肝移植中选择合适的候选者对于改善结果至关重要，尽管目前的标准无法识别出再次肝移植会被禁忌的单一患者亚组。
