Rana Abbas, Kueht Michael, Desai Moreshwar, Lam Fong, Miloh Tamir, Moffett Jennifer, Galvan N Thao N, Cotton Ronald, O'Mahony Christine, Goss John
Michael E DeBakey Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX.
Michael E DeBakey Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX.
J Am Coll Surg. 2017 Apr;224(4):671-677. doi: 10.1016/j.jamcollsurg.2016.12.025. Epub 2017 Feb 3.
Advances in critical care prolong survival in children with liver failure, allowing more critically ill children to undergo orthotopic liver transplantation (OLT). In order to justify the use of a scarce donor resource and avoid futile transplants, we sought to determine survival in children who undergo OLT while receiving pre-OLT critical care.
We analyzed 13,723 pediatric OLTs using the United Network for Organ Sharing (UNOS) database from 1987 to 2015, including 6,746 recipients in the Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease (MELD/PELD) era (2002 to 2015). There were 1,816 recipients (26.9%) admitted to the ICU at the time of transplantation. We also analyzed 354 pediatric OLT recipients at our center from 2002 to 2015, one of the largest institutional experiences. Sixty-five recipients (18.3%) were admitted to the ICU at the time of transplantation. Kaplan-Meier, volume threshold, and multivariable analyses were performed.
Patient survival improved steadily over the study period, (66% 1-year survival in 1987 vs 92% in 2015; p < 0.001). Our institutional experience of ICU recipients in the MELD/PELD era had acceptable outcomes (87% 1-year survival), even among our sickest recipients with vasoactive medications, mechanical ventilation, dialysis, and molecular adsorbent recirculating system requirements. Volume analysis revealed inferior outcomes (hazard ratio [HR] 1.68; 95% CI 1.11 to 2.51) in low-volume centers (<5 annual cases). Identifiable risk factors (previous transplantation, elevated serum sodium, hemodialysis, mechanical ventilation, body weight < 6 kg, and low center volume) increased risk of mortality.
This analysis demonstrates that the use of advanced critical care in children and infants with liver failure is justified because OLT can be performed on the sickest children and acceptable outcomes achieved. It is an appropriate use of a scarce donor allograft in a child who would otherwise succumb to a terminal liver disease.
重症监护技术的进步延长了肝功能衰竭患儿的生存期，使更多重症患儿能够接受原位肝移植（OLT）。为了合理使用稀缺的供体资源并避免无效移植，我们试图确定在接受OLT前接受重症监护的患儿的生存率。
我们使用器官共享联合网络（UNOS）数据库分析了1987年至2015年期间的13723例小儿OLT，其中包括终末期肝病/小儿终末期肝病模型（MELD/PELD）时代（2002年至2015年）的6746例受者。有1816例受者（26.9%）在移植时入住重症监护病房（ICU）。我们还分析了2002年至2015年期间我们中心的354例小儿OLT受者，这是最大的机构经验之一。65例受者（18.3%）在移植时入住ICU。进行了Kaplan-Meier分析、容量阈值分析和多变量分析。
在研究期间，患者生存率稳步提高（1987年1年生存率为66%，2015年为92%；p<0.001）。我们在MELD/PELD时代对ICU受者的机构经验有可接受的结果（1年生存率为87%），即使在我们最病重的需要血管活性药物、机械通气、透析和分子吸附循环系统的受者中也是如此。容量分析显示，低容量中心（每年病例数<5例）的结果较差（风险比[HR]为1.68；95%可信区间为1.11至2.51）。可识别的风险因素（既往移植、血清钠升高、血液透析、机械通气、体重<6kg和中心容量低）增加了死亡风险。
该分析表明，在肝功能衰竭的儿童和婴儿中使用先进的重症监护是合理的，因为可以对最病重的儿童进行OLT并取得可接受的结果。这是对稀缺的供体同种异体移植物的适当使用，否则这些儿童会死于终末期肝病。
