Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
Hepatology. 2012 Jan;55(1):192-8. doi: 10.1002/hep.24632. Epub 2011 Nov 15.
Candidates with fulminant hepatic failure (Status-1A) receive the highest priority for liver transplantation (LT) in the United States. However, no studies have compared wait-list mortality risk among end-stage liver disease (ESLD) candidates with high Model for End-Stage Liver Disease (MELD) scores to those listed as Status-1A. We aimed to determine if there are MELD scores for ESLD candidates at which their wait-list mortality risk is higher than that of Status-1A, and to identify the factors predicting wait-list mortality among those who are Status-1A. Data were obtained from the Scientific Registry of Transplant Recipients for adult LT candidates (n = 52,459) listed between September 1, 2001, and December 31, 2007. Candidates listed for repeat LT as Status-1 A were excluded. Starting from the date of wait listing, candidates were followed for 14 days or until the earliest occurrence of death, transplant, or granting of an exception MELD score. ESLD candidates were categorized by MELD score, with a separate category for those with calculated MELD > 40. We compared wait-list mortality between each MELD category and Status-1A (reference) using time-dependent Cox regression. ESLD candidates with MELD > 40 had almost twice the wait-list mortality risk of Status-1A candidates, with a covariate-adjusted hazard ratio of HR = 1.96 (P = 0.004). There was no difference in wait-list mortality risk for candidates with MELD 36-40 and Status-1A, whereas candidates with MELD < 36 had significantly lower mortality risk than Status-1A candidates. MELD score did not significantly predict wait-list mortality among Status-1A candidates (P = 0.18). Among Status-1A candidates with acetaminophen toxicity, MELD was a significant predictor of wait-list mortality (P < 0.0009). Posttransplant survival was similar for Status-1A and ESLD candidates with MELD > 20 (P = 0.6).
Candidates with MELD > 40 have significantly higher wait-list mortality and similar posttransplant survival as candidates who are Status-1A, and therefore, should be assigned higher priority than Status-1A for allocation. Because ESLD candidates with MELD 36-40 and Status-1A have similar wait-list mortality risk and posttransplant survival, these candidates should be assigned similar rather than sequential priority for deceased donor LT.
本研究旨在确定终末期肝病（ESLD）候选者的 MELD 评分是否存在高于状态 1A 的等待名单死亡率风险，并确定状态 1A 患者等待名单死亡率的预测因素。
从 2001 年 9 月 1 日至 2007 年 12 月 31 日，从科学移植受者登记处获取接受成人肝移植（LT）候选者的数据（n=52459）。排除作为状态 1A 再次列出的候选者。从等待名单日期开始，对候选者进行 14 天或直至死亡、移植或授予例外 MELD 评分的最早发生时间的随访。根据 MELD 评分对 ESLD 候选者进行分类，对计算的 MELD>40 的候选者单独分类。使用时间依赖性 Cox 回归比较每个 MELD 类别与状态 1A（参考）之间的等待名单死亡率。MELD>40 的 ESLD 候选者的等待名单死亡率风险几乎是状态 1A 候选者的两倍，校正协变量后的危险比 HR=1.96（P=0.004）。MELD36-40 和状态 1A 候选者的等待名单死亡率风险无差异，而 MELD<36 的候选者的死亡率风险明显低于状态 1A 候选者。MELD 评分不能显著预测状态 1A 候选者的等待名单死亡率（P=0.18）。在有乙酰氨基酚毒性的状态 1A 候选者中，MELD 是等待名单死亡率的显著预测因素（P<0.0009）。状态 1A 和 MELD>20 的 ESLD 候选者的移植后生存率相似（P=0.6）。
MELD>40 的候选者的等待名单死亡率明显较高，与状态 1A 候选者的移植后生存率相似，因此，应比状态 1A 候选者优先分配。由于 MELD36-40 和状态 1A 的 ESLD 候选者的等待名单死亡率风险和移植后生存率相似，因此应优先分配相似而不是顺序分配给已故供体 LT。
