Buchholz Bettina M, Khan Shakeeb, David Miruna D, Gunson Bridget K, Isaac John R, Roberts Keith J, Muiesan Paolo, Mirza Darius F, Tripathi Dhiraj, Perera M Thamara P R
Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom.
Clinical Microbiology Department, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom.
Transplant Direct. 2017 Jul 5;3(8):e186. doi: 10.1097/TXD.0000000000000705. eCollection 2017 Aug.
Definitive treatment for late hepatic artery thrombosis (L-HAT) is retransplantation (re-LT); however, the L-HAT-associated disease burden is poorly represented in allocation models.
Graft access and transplant outcome of the re-LT experience between 2005 and 2016 was reviewed with specific focus on the L-HAT cohort in this single-center retrospective study.
Ninety-nine (5.7%) of 1725 liver transplantations were re-LT with HAT as the main indication (n = 43; 43%) distributed into early (n = 25) and late (n = 18) episodes. Model for end-stage liver disease as well as United Kingdom model for end-stage liver disease did not accurately reflect high disease burden of graft failure associated infections such as hepatic abscesses and biliary sepsis in L-HAT. Hence, re-LT candidates with L-HAT received low prioritization and waited longest until the allocation of an acceptable graft (median, 103 days; interquartile range, 28-291 days), allowing for progression of biliary sepsis. Balance of risk score and 3-month mortality score prognosticated good transplant outcome in L-HAT but, contrary to the prediction, the factual 1-year patient survival after re-LT was significantly inferior in L-HAT compared to early HAT, early non-HAT and late non-HAT (65% vs 82%, 92% and 95%) which was mainly caused by sepsis and multiorgan failure driving 3-month mortality (28% vs 11%, 16% and 0%). Access to a second graft after a median waitlist time of 6 weeks achieved the best short- and long-term outcome in re-LT for L-HAT (3-month mortality, 13%; 1-year survival, 77%).
Inequity in graft access and peritransplant sepsis are fundamental obstacles for successful re-LT in L-HAT. Offering a graft for those in need at the best window of opportunity could facilitate earlier engrafting with improved outcomes.
晚期肝动脉血栓形成（L-HAT）的确定性治疗方法是再次移植（re-LT）；然而，L-HAT相关的疾病负担在分配模型中未得到充分体现。
在这项单中心回顾性研究中，回顾了2005年至2016年期间re-LT的移植物获取情况和移植结果，特别关注L-HAT队列。
1725例肝移植中有99例（5.7%）进行了re-LT，其中以肝动脉血栓形成作为主要指征（n = 43；43%），分为早期（n = 25）和晚期（n = 18）发作。终末期肝病模型以及英国终末期肝病模型未能准确反映L-HAT中移植物失败相关感染（如肝脓肿和胆源性败血症）的高疾病负担。因此，患有L-HAT的再次移植候选者获得的优先级较低，等待可接受移植物分配的时间最长（中位数为103天；四分位间距为28 - 291天），从而导致胆源性败血症进展。风险评分和3个月死亡率评分的平衡预测L-HAT的移植结果良好，但与预测相反，与早期肝动脉血栓形成、早期非肝动脉血栓形成和晚期非肝动脉血栓形成相比，L-HAT再次移植后实际的1年患者生存率显著较低（65%对82%、92%和95%），这主要是由败血症和多器官功能衰竭导致3个月死亡率升高所致（28%对11%、16%和0%）。在等待名单中位数时间6周后获得第二个移植物，在L-HAT的再次移植中实现了最佳的短期和长期结果（3个月死亡率为13%；1年生存率为77%）。
移植物获取不平等和移植周围败血症是L-HAT成功进行再次移植的基本障碍。在最佳时机为有需要的人提供移植物可以促进更早的植入并改善结果。
