Murillas Javier, Rimola Antonio, Laguno Montserrat, de Lazzari Elisa, Rascón Javier, Agüero Fernando, Blanco José L, Moitinho Eduardo, Moreno Asunción, Miró José M
Hospital Son Dureta, Palma de Mallorca, Spain.
Liver Transpl. 2009 Sep;15(9):1133-41. doi: 10.1002/lt.21735.
End-stage liver disease (ESLD) has become the main cause of mortality in patients coinfected by human immunodeficiency virus (HIV) and hepatitis B virus or hepatitis C virus in developed countries. The aim of this study was to describe the natural history of and prognostic factors for ESLD, with particular attention paid to features affecting liver transplantation. This was a prospective cohort study in 2 Spanish community-based hospitals performed between 1999 and 2004. One hundred four consecutive patients with cirrhosis and a first clinical decompensation of their chronic liver disease or hepatocellular carcinoma were included in the study. During a median follow-up of 10 months (endpoint: death, liver transplantation, or the last checkup date), 61 patients (59%) died. The probability of mortality (Kaplan-Meier method) at 1, 2, and 3 years was 43% [95% confidence interval (CI), 34%-60%], 59% (95% CI, 48%-70%), and 70% (95% Cl, 59%-81%), respectively. In a multivariate analysis, the Model for End-Stage Liver Disease (MELD) score and the inability to reach an undetectable plasma HIV-1 RNA viral load at any time during follow-up were the only variables independently associated with the risk of death (P < 0.001). Fifteen (14%) of the 104 patients were accepted for liver transplantation, although only 5 underwent the procedure, and 10 died while on the waiting list. The waiting list mortality rate in patients with a MELD score < 20 and in patients with a MELD score >20 was 58% and 100%, respectively (median follow-up, 5 months). In conclusion, HIV-1-infected patients with ESLD, especially those with poorly controlled HIV and a high MELD score, have a poor short-term outcome. The MELD score may be useful in deciding whether to indicate liver transplantation in these patients. However, because only a small proportion of the patients in this study were considered candidates for liver transplantation and most died while on the waiting list, few received a transplant.
在发达国家，终末期肝病（ESLD）已成为人类免疫缺陷病毒（HIV）与乙型肝炎病毒或丙型肝炎病毒合并感染患者的主要死亡原因。本研究旨在描述ESLD的自然病程及预后因素，尤其关注影响肝移植的特征。这是一项于1999年至2004年在西班牙2家社区医院开展的前瞻性队列研究。104例连续性肝硬化患者及首次出现慢性肝病临床失代偿或肝细胞癌的患者被纳入研究。在中位随访10个月期间（终点：死亡、肝移植或最后一次检查日期），61例患者（59%）死亡。1年、2年和3年的死亡概率（Kaplan-Meier法）分别为43%[95%置信区间（CI），34%-60%]、59%（95%CI，48%-70%）和70%（95%CI，59%-81%）。多因素分析显示，终末期肝病模型（MELD）评分以及随访期间任何时间均无法使血浆HIV-1 RNA病毒载量降至检测不到水平是与死亡风险独立相关的唯一变量（P<0.001）。104例患者中有15例（14%）被接受肝移植评估，尽管仅5例接受了手术，10例在等待名单上死亡。MELD评分<20的患者和MELD评分>20的患者等待名单死亡率分别为58%和100%（中位随访时间，5个月）。总之，合并ESLD的HIV-1感染患者，尤其是HIV控制不佳且MELD评分高的患者，短期预后较差。MELD评分可能有助于决定是否对这些患者进行肝移植。然而，由于本研究中仅一小部分患者被视为肝移植候选者，且大多数在等待名单上死亡，接受移植的患者很少。
