Division of Gastroenterology and Hepatology, Department of Medicine, San Francisco General Hospital, San Francisco, CA 94110, USA.
Liver Transpl. 2011 Feb;17(2):129-36. doi: 10.1002/lt.22218.
Donor livers are offered to patients with the highest risk of death. How ascites could inform risk models to reduce liver transplant wait-list mortality is unclear. All adult candidates for primary liver transplantation for cirrhosis without exception points who were registered with the Organ Procurement and Transplantation Network from 2005 to 2007 composed our study cohort. Using Cox models and advanced discriminative metrics and paying attention to geographic disparities, we evaluated the additional risk discrimination of moderate ascites over that of the Model for End-Stage Liver Disease (MELD) or the Model for End-Stage Liver Disease plus serum sodium (MELD-Na) alone for the prediction of 90-day wait-list mortality. Additional analyses examined lower mortality risk candidates and those listed in high-demand, low-supply United Network for Organ Sharing regions in which accounting for ascites may most significantly affect wait-list mortality. Between 2005 and 2007, 18,124 subjects were listed for liver transplantation. Mortality was higher in patients with moderate ascites (15.4% versus 6.0%, P < 0.0001), and this risk persisted despite adjustments for MELD (hazard ratio = 1.58, 95% confidence interval = 1.42-1.76) and MELD-Na (hazard ratio = 1.42, 95% confidence interval = 1.28-1.58). The effect of moderate ascites was more prominent with a MELD score <21 (equal to 4.7 MELD units) or with a MELD-Na score <21 (equal to 3.5 MELD-Na units). Wait-list mortality was higher in patients with moderate ascites who were listed in high-demand, limited-supply regions (25.8% versus 17.5% at 1 year, P < 0.01). With the addition of moderate ascites, there was improvement in the overall risk model, particularly with a MELD score <21, as measured by the C index and integrated discrimination improvement. Moderate ascites informed risk prediction, particularly with a MELD score <21 and in high-demand, limited-supply regions. Under the MELD system, the presence of moderate ascites should prompt clinicians to consider strategies to expand access to transplantation, such as the use of extended donor liver grafts.
供体肝脏提供给死亡风险最高的患者。腹水如何为风险模型提供信息，以降低肝移植等待名单死亡率尚不清楚。2005 年至 2007 年，我们的研究队列由在器官获取和移植网络上登记的所有因肝硬化而进行原发性肝移植且无一例外地获得最高分数的成年候选者组成。我们使用 Cox 模型和先进的判别指标，并关注地理差异，评估中度腹水对 MELD（终末期肝病模型）或 MELD 加血清钠（MELD-Na）单独预测 90 天等待名单死亡率的额外风险区分能力。进一步的分析考察了低死亡率风险候选者和在供过于求、低供应的美国器官共享网络地区列出的候选者，在这些地区，腹水的考虑可能会对等待名单死亡率产生最大影响。2005 年至 2007 年，有 18124 名患者被列入肝移植名单。有中度腹水的患者死亡率更高（15.4%比 6.0%，P<0.0001），尽管调整了 MELD（风险比=1.58，95%置信区间=1.42-1.76）和 MELD-Na（风险比=1.42，95%置信区间=1.28-1.58），但这种风险仍然存在。在 MELD 评分<21（相当于 4.7 MELD 单位）或 MELD-Na 评分<21（相当于 3.5 MELD-Na 单位）的情况下，中度腹水的影响更为显著。在需求高、供应有限的地区，有中度腹水的患者等待名单死亡率更高（1 年时为 25.8%比 17.5%，P<0.01）。通过加入中度腹水，特别是在 MELD 评分<21 的情况下，通过 C 指数和综合鉴别改善，整个风险模型得到了改善。中度腹水为风险预测提供了信息，特别是在 MELD 评分<21 和需求高、供应有限的地区。在 MELD 系统下，中度腹水的存在应促使临床医生考虑扩大移植机会的策略，例如使用扩展供体肝移植。
