Stine Jonathan G, Northup Patrick G, Stukenborg George J, Cornella Scott L, Maluf Daniel G, Pelletier Shawn J, Argo Curtis K
Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA.
Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA.
Hepatol Res. 2018 Mar;48(4):225-232. doi: 10.1111/hepr.12922. Epub 2017 Aug 30.
Geographic disparities persist in the USA despite locoregional organ sharing policies. The impact of national organ sharing policies on waiting-list mortality on a regional basis remains unknown.
Data on all adult liver transplants between 1 February 2002 and 31 March 2015 were obtained from the United Network for Organ Sharing/Organ and Transplantation Network. Multivariable Cox proportional hazards models were constructed in a time-to-event analysis to estimate waiting-list mortality for the pre- and post-Share35 eras.
In the analyzed time period, 134 247 patients were listed for transplantation and 54 510 received organs (42.8%). Listing volume increased following the introduction of the Share35 organ sharing policy (15 976 candidates pre- vs. 18 375 post) without significant regional changes as did the number of transplants (7210 pre- vs. 8224 post). Waiting-list mortality improved from 12.2% to 8.1% (P < 0.001). Adjusted waiting-list mortality ratios remained geographically disparate. Region 10 and region 11 had lower hazard ratios (HR) but still had increased mortality (1.46, 95% confidence interval [CI] 1.34-1.60, P < 0.001; and HR 1.49, 95% CI 1.37-1.62, P < 0.001, respectively). Regions 3 and 6 had increased HR with persistently elevated waiting-list mortality (1.79, 95% CI 1.66-1.93, P < 0.001; and HR 1.29, 95% CI 1.16-1.45, P < 0.001, respectively). Model for End-state Liver Disease (MELD) exception continued to propagate a survival benefit (HR 0.65, 95% CI 0.63-0.68, P < 0.001).
Although overall waiting-list mortality has decreased, geographic disparities persist, but appear reduced despite broader sharing policies enacted by Share35. The advantage afforded by MELD exception, while still present, was diminished by Share35 as organs are being shifted to MELD >35 candidates. The disparities highlighted by our findings imply a need to review current allocation policies to best balance local, regional, and national transplant environments.
尽管实施了局部区域器官共享政策，但美国的地理差异仍然存在。国家器官共享政策对区域等待名单死亡率的影响尚不清楚。
从器官共享联合网络/器官移植网络获取2002年2月1日至2015年3月31日期间所有成人肝移植的数据。在事件发生时间分析中构建多变量Cox比例风险模型，以估计Share35时代前后的等待名单死亡率。
在分析的时间段内，有134247名患者被列入移植名单，54510名患者接受了器官移植（42.8%）。引入Share35器官共享政策后，列入名单的人数有所增加（之前为15976名候选人，之后为18375名），各区域没有显著变化，移植数量也是如此（之前为7210例，之后为8224例）。等待名单死亡率从12.2%降至8.1%（P<0.001）。调整后的等待名单死亡率在地理上仍然存在差异。第10区和第11区的风险比（HR）较低，但死亡率仍有所上升（分别为1.46，95%置信区间[CI]1.34-1.60，P<0.001；HR 1.49，95%CI 1.37-1.62，P<0.001）。第3区和第6区的HR增加，等待名单死亡率持续升高（分别为1.79，95%CI 1.66-1.93，P<0.001；HR 1.29，95%CI 1.16-1.45，P<0.001）。终末期肝病模型（MELD）例外情况继续带来生存益处（HR 0.65，95%CI 0.63-0.68，P<0.001）。
虽然总体等待名单死亡率有所下降，但地理差异仍然存在，不过尽管Share35实施了更广泛的共享政策，差异似乎有所减少。MELD例外情况带来的优势虽然仍然存在，但由于器官被转移到MELD>35的候选人身上，Share35使其有所减弱。我们的研究结果突出的差异意味着需要审查当前的分配政策，以最好地平衡地方、区域和国家的移植环境。
