Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 9 Penn Tower, Philadelphia, PA 19104, USA.
Liver Transpl. 2013 Mar;19(3):250-8. doi: 10.1002/lt.23587.
Patients with primary sclerosing cholangitis (PSC) are at increased risk for bacterial cholangitis because of biliary strictures and bile stasis. A subset of PSC patients suffer from repeated episodes of bacterial cholangitis, which can lead to frequent hospitalizations and impaired quality of life. Although waitlist candidates with PSC and bacterial cholangitis frequently receive exception points and/or are referred for living donor transplantation, the impact of bacterial cholangitis on waitlist mortality is unknown. We performed a retrospective cohort study of all adult waitlist candidates with PSC who were listed for initial transplantation between February 27, 2002 and June 1, 2012 at the University of Pennsylvania and the University of Colorado-Denver. During this period, 171 PSC patients were waitlisted for initial transplantation. Before waitlisting, 38.6% (66/171) of the patients had a history of bacterial cholangitis, whereas 28.0% (44/157) of the patients with at least 1 Model for End-Stage Liver Disease update experienced cholangitis on the waitlist. During follow-up, 30 patients (17.5%) were removed from the waitlist for death or clinical deterioration, with 46.7% (14/30) developing cholangiocarcinoma. Overall, 12 of the 82 waitlist candidates (14.6%) who ever had an episode of cholangitis were removed for death or clinical deterioration, whereas 18 of the 89 candidates (20.2%) without cholangitis were removed (P = 0.34 for a comparison of the 2 groups). No patients were removed because of bacterial cholangitis. In multivariate competing-risk models, a history of bacterial cholangitis was not associated with an increased risk of waitlist removal for death or clinical deterioration (subhazard ratio = 0.67, 95% confidence interval = 0.65-0.70, P < 0.001). In summary, waitlist transplant candidates with PSC and bacterial cholangitis do not have an increased risk of waitlist mortality. The data call into question the systematic granting of exception points or referral for living donor transplantation due to a perceived risk of increased waitlist mortality.
原发性硬化性胆管炎 (PSC) 患者由于胆管狭窄和胆汁淤积，患细菌性胆管炎的风险增加。一部分 PSC 患者反复发作细菌性胆管炎，这可能导致频繁住院和生活质量受损。尽管 PSC 合并细菌性胆管炎的候补患者经常获得例外积分和/或被推荐进行活体供者移植，但细菌性胆管炎对候补患者死亡率的影响尚不清楚。我们对 2002 年 2 月 27 日至 2012 年 6 月 1 日期间在宾夕法尼亚大学和科罗拉多大学丹佛分校接受初始移植的所有成年 PSC 候补患者进行了回顾性队列研究。在此期间，有 171 名 PSC 患者被列入初始移植候补名单。在列入候补名单之前，38.6%（66/171）的患者有细菌性胆管炎病史，而在至少经历过 1 次终末期肝病模型更新的 157 名患者中，有 28.0%（44/157）在候补名单期间发生胆管炎。在随访期间，有 30 名患者（17.5%）因死亡或临床恶化而从候补名单中移除，其中 46.7%（14/30）发生胆管癌。总体而言，82 名候补患者中有 12 名（14.6%）因胆管炎发作而被移除，因死亡或临床恶化而被移除，而 89 名无胆管炎的患者中有 18 名（20.2%）被移除（比较两组，P=0.34）。没有患者因细菌性胆管炎而被移除。在多变量竞争风险模型中，细菌性胆管炎病史与候补患者因死亡或临床恶化而被移除的风险增加无关（亚危险比=0.67，95%置信区间=0.65-0.70，P<0.001）。总之，PSC 合并细菌性胆管炎的候补移植患者的候补死亡率没有增加。这些数据质疑了由于认为候补死亡率增加而给予例外积分或推荐活体供者移植的系统性做法。
