Massie Allan B, Luo Xun, Alejo Jennifer L, Poon Anna K, Cameron Andrew M, Segev Dorry L
Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.
Liver Transpl. 2015 May;21(5):683-9. doi: 10.1002/lt.24102. Epub 2015 Apr 1.
Liver allocation is based on current Model for End-Stage Liver Disease (MELD) scores, with priority in the case of a tie being given to those waiting the longest with a given MELD score. We hypothesized that this priority might not reflect risk: registrants whose MELD score has recently increased receive lower priority but might have higher wait-list mortality. We studied wait-list and posttransplant mortality in 69,643 adult registrants from 2002 to 2013. By likelihood maximization, we empirically defined a MELD spike as a MELD increase ≥ 30% over the previous 7 days. At any given time, only 0.6% of wait-list patients experienced a spike; however, these patients accounted for 25% of all wait-list deaths. Registrants who reached a given MELD score after a spike had higher wait-list mortality in the ensuing 7 days than those with the same resulting MELD score who did not spike, but they had no difference in posttransplant mortality. The spike-associated wait-list mortality increase was highest for registrants with medium MELD scores: specifically, 2.3-fold higher (spike versus no spike) for a MELD score of 10, 4.0-fold higher for a MELD score of 20, and 2.5-fold higher for a MELD score of 30. A model incorporating the MELD score and spikes predicted wait-list mortality risk much better than a model incorporating only the MELD score. Registrants with a sudden MELD increase have a higher risk of short-term wait-list mortality than is indicated by their current MELD score but have no increased risk of posttransplant mortality; allocation policy should be adjusted accordingly.
肝脏分配基于当前的终末期肝病模型（MELD）评分，在评分相同的情况下，优先考虑等待时间最长的患者。我们推测这种优先顺序可能无法反映风险：MELD评分近期升高的登记者获得的优先级较低，但可能有更高的等待名单死亡率。我们研究了2002年至2013年69643名成年登记者在等待名单上的死亡率和移植后的死亡率。通过似然最大化，我们根据经验将MELD峰值定义为在过去7天内MELD升高≥30%。在任何给定时间，等待名单上只有0.6%的患者经历了峰值；然而，这些患者占所有等待名单死亡人数的25%。在峰值后达到给定MELD评分的登记者在随后7天内的等待名单死亡率高于未出现峰值但最终MELD评分相同的登记者，但他们在移植后的死亡率没有差异。MELD评分中等的登记者与峰值相关的等待名单死亡率增加最高：具体而言，MELD评分为10时，峰值组比无峰值组高2.3倍；MELD评分为20时，高4.0倍；MELD评分为30时，高2.5倍。一个纳入MELD评分和峰值的模型比仅纳入MELD评分的模型能更好地预测等待名单死亡率风险。MELD突然升高的登记者短期等待名单死亡率风险高于其当前MELD评分所显示的风险，但移植后死亡率没有增加；分配政策应相应调整。
