2nd Medical Department, Technische Universität München, Munich, Germany.
Institute of Medical Statistics and Epidemiology, Technische Universität München, Munich, Germany.
Liver Transpl. 2017 Oct;23(10):1256-1265. doi: 10.1002/lt.24805.
The sickest-first principle in donor-liver allocation can be implemented by allocating organs to patients with cirrhosis with the highest Model for End-Stage Liver Disease (MELD) scores. For patients with other risk factors, standard exceptions (SEs) and nonstandard exceptions (NSEs) have been developed. We investigated whether this system of matched MELD scores achieves similar outcomes on the liver transplant waiting list for various diagnostic groups in Eurotransplant (ET) countries with MELD-based individual allocation (Belgium, the Netherlands, and Germany). A retrospective analysis of the ET wait-list outflow from December 2006 until December 2015 was conducted to investigate the relation of the unified MELD-based allocation to the risk of a negative wait-list outcome (death on the waiting list or delisting as too sick) as opposed to a positive wait-list outcome (transplantation or delisting as recovered). A total of 16,926 patients left the waiting list with a positive (11,580) or negative (5346) outcome; 3548 patients had a SE, and 330 had a NSE. A negative outcome was more common among patients without a SE or NSE (34.3%) than among patients with a SE (22.6%) or NSE (18.6%; P < 0.001). Analysis by model-based recursive partitioning detected 5 risk groups with different relations of matched MELD to a negative outcome. In Germany, we found the following: (1) no SE or NSE, SE for biliary sepsis (BS); (2) SE for hepatocellular carcinoma (HCC), hepatopulmonary syndrome (HPS), or portopulmonary hypertension (PPH); and (3) SE for primary sclerosing cholangitis (PSC) or polycystic liver disease (PcLD). In Belgium and the Netherlands, we found the following: (4) SE or NSE, or SE for HPS or PPH; and (5) SE for BS, HCC, PcLD, or PSC. In conclusion, SEs and NSEs do not even out risks across different diagnostic groups. Patients with SEs or NSEs appear advantaged toward patients with cirrhosis without SEs or NSEs. Liver Transplantation 23 1256-1265 2017 AASLD.
在供肝分配中，采用最病重患者优先的原则，即根据终末期肝病模型（MELD）评分，将器官分配给肝硬化程度最高的患者。对于具有其他风险因素的患者，已经制定了标准例外（SE）和非标准例外（NSE）。我们研究了在欧洲肝移植组织（ET）国家中，对于基于 MELD 的个体分配，这种匹配 MELD 评分的系统在各种诊断组的肝移植等待名单上是否能取得类似的结果。对 2006 年 12 月至 2015 年 12 月 ET 等待名单的流出情况进行了回顾性分析，以调查统一基于 MELD 的分配与等待名单不良结局（等待名单上死亡或因病情过重而被除名）的风险之间的关系，而不是等待名单的良好结局（移植或因康复而被除名）。共有 16926 名患者的等待名单结果为阳性（11580 名）或阴性（5346 名）；3548 名患者有 SE，330 名患者有 NSE。无 SE 或 NSE 的患者（34.3%）出现阴性结果的比例高于有 SE（22.6%）或 NSE（18.6%）的患者（P < 0.001）。基于模型的递归分区分析发现，有 5 个不同风险组与匹配 MELD 与不良结果的关系不同。在德国，我们发现：（1）无 SE 或 NSE，SE 用于胆管炎（BS）；（2）SE 用于肝细胞癌（HCC）、肝肺综合征（HPS）或门肺高压（PPH）；（3）SE 用于原发性硬化性胆管炎（PSC）或多囊肝病（PcLD）。在比利时和荷兰，我们发现：（4）SE 或 NSE，或 SE 用于 HPS 或 PPH；（5）SE 用于 BS、HCC、PcLD 或 PSC。总之，SE 和 NSE 并不能平衡不同诊断组之间的风险。具有 SE 或 NSE 的患者似乎比没有 SE 或 NSE 的肝硬化患者更有优势。肝移植 23 1256-1265 2017 AASLD。
