Goldberg David S, Levine Matthew, Karp Seth, Gilroy Richard, Abt Peter L
Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, PA.
Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
Liver Transpl. 2017 May;23(5):604-613. doi: 10.1002/lt.24749.
Share 35 was implemented to provide improved access to organs for patients with Model for End-Stage Liver Disease (MELD) scores ≥ 35. However, little is known about the impact of Share 35 on organ offer acceptance rates. We evaluated all liver offers to adult patients who were ultimately transplanted between January 1, 2011 and December 31, 2015. The analyses focused on patients ranked in the top 5 positions of a given match run and used multilevel mixed-effects models, clustering on individual wait-list candidate and transplant center. There was a significant interaction between Share 35 era and MELD category (P < 0.001). Comparing offers to MELD score ≥ 35 patients, offers after Share 35 were 36% less likely to be accepted compared with offers to MELD score ≥ 35 patients before Share 35 (adjusted odds ratio, 0.64). There was no clinically meaningful difference in the donor risk index of livers that were declined for patients with an allocation MELD score ≥35 in the pre- versus post-Share 35 era. Organ offer acceptance rates for patients with an allocation MELD ≥ 35 decreased in every region after Share 35; the magnitude of these changes was bigger in regions 2, 3, 4, 5, 6, 7, and 11, compared with regions 8 and 9 that had regional sharing in place before Share 35. There were significant changes in organ offer acceptance rates at the center level before versus after Share 35, and these changes varied across centers (P < 0.001). In conclusion, in liver transplantation candidates achieving a MELD score ≥ 35, liver acceptance of offers declined significantly after implementation of Share 35. The alterations in behavior at the center level suggest that practice patterns changed as a direct result of Share 35. Changes in organ acceptance under even broader organ sharing (redistricting) would likely be even greater, posing major logistical and operational challenges, while potentially increasing discard rates, thus decreasing the total number of transplants nationally. Liver Transplantation 23 604-613 2017 AASLD.
实施“共享35”政策是为了让终末期肝病模型（MELD）评分≥35的患者有更多机会获得器官。然而，对于“共享35”政策对器官接受率的影响知之甚少。我们评估了2011年1月1日至2015年12月31日期间最终接受移植的成年患者所获得的所有肝脏供体。分析聚焦于在给定匹配轮次中排名前5位的患者，并使用多层次混合效应模型，按个体等待名单候选人和移植中心进行聚类分析。“共享35”时代与MELD类别之间存在显著交互作用（P < 0.001）。与“共享35”政策实施前向MELD评分≥35的患者提供的肝脏相比，“共享35”政策实施后向MELD评分≥35的患者提供的肝脏被接受的可能性降低了36%（调整后的优势比为0.64）。在“共享35”政策实施前和实施后，分配MELD评分≥35的患者拒绝的肝脏的供体风险指数在临床上没有显著差异。“共享35”政策实施后，每个地区分配MELD≥35的患者的器官接受率均有所下降；与“共享35”政策实施前就已实行区域共享的8区和9区相比，2区、3区、4区、5区、6区、7区和11区的这些变化幅度更大。“共享35”政策实施前后，各中心的器官接受率有显著变化，且这些变化因中心而异（P < 0.001）。总之，在MELD评分≥35的肝移植候选患者中，“共享35”政策实施后肝脏接受率显著下降。中心层面行为的改变表明，实践模式因“共享35”政策而直接发生了变化。在更广泛的器官共享（重新划分区域）情况下，器官接受率的变化可能会更大，这将带来重大的后勤和运营挑战，同时可能会提高丢弃率，从而减少全国范围内的移植总数。《肝脏移植》2017年第23卷，604 - 613页，美国肝脏研究协会
