三十年 1000 例小儿肝移植：经验教训。

One Thousand Pediatric Liver Transplants During Thirty Years: Lessons Learned.

机构信息

Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA.

Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA.

出版信息

J Am Coll Surg. 2018 Apr;226(4):355-366. doi: 10.1016/j.jamcollsurg.2017.12.042. Epub 2018 Feb 2.

DOI:10.1016/j.jamcollsurg.2017.12.042

PMID:29410290

Abstract

BACKGROUND

Pediatric liver transplantation (pLTx) has been the standard of care for children with liver failure since the 1980s. This study examined the world's largest single-center experience and aimed to identify unique preoperative predictors of early graft and patient survival for primary transplantation (1°-pLTx) and retransplantation (Re-pLTx).

STUDY DESIGN

We conducted an IRB-approved, retrospective study of all consecutive, isolated pLTx patients 18 years of age or younger. Twenty-eight demographic, laboratory, and perioperative variables were analyzed as potential outcome predictors. Univariate and multivariate analyses were performed using log-rank test and Cox's proportional hazards model.

RESULTS

There were 806 children who received 1,016 isolated pLTx between February1984 and June 2017. Median follow-up was 12 years. Leading indications for pLTx were cholestatic liver disease (40%), re-pLTx (21%), and fulminant hepatic failure (14%). Seventy-three percent received cadaveric whole grafts. Overall graft and patient survival rates at 0.5, 1, 5, 10, and 20 years were: 76%, 73%, 67%, 63%, 53%, and 87%, 86%, 81%, 78%, 69%, respectively. Relative to 1°-pLTx, re-pLTx recipients were significantly older, larger, with worse renal function, and more likely to be awaiting pLTx in an ICU. Independent significant predictors of graft survival for 1°-pLTx included weight, transplantation era, and renal replacement therapy; for re-pLTx, warm ischemia time and time between 1°-pLTx and re-pLTx. Independent significant predictors of patient survival were renal function, mechanical ventilation, and etiology of liver disease.

CONCLUSIONS

This is the largest reported single-center experience of pLTx with substantial follow-up time and a large re-pLTx experience. Important transplant predictors of graft survival include weight, renal function, modern era, warm ischemia time, and time between primary transplantation and re-pLTx. Renal function, mechanical ventilation, and underlying cause of liver disease affect patient survival. Awareness of these factors can help in the decision making for children requiring pLTx.

摘要

背景

自 20 世纪 80 年代以来，儿科肝移植（pLTx）已成为治疗肝衰竭儿童的标准治疗方法。本研究检查了世界上最大的单中心经验，并旨在确定原发性移植（1°-pLTx）和再移植（Re-pLTx）的早期移植物和患者生存的独特术前预测因素。

研究设计

我们对所有 18 岁或以下的连续、孤立的 pLTx 患者进行了经 IRB 批准的回顾性研究。分析了 28 个人口统计学、实验室和围手术期变量作为潜在的结果预测因素。使用对数秩检验和 Cox 比例风险模型进行单变量和多变量分析。

结果

1984 年 2 月至 2017 年 6 月期间，共有 806 名儿童接受了 1016 例孤立性 pLTx。中位随访时间为 12 年。pLTx 的主要适应证为胆汁淤积性肝病（40%）、再移植（21%）和暴发性肝衰竭（14%）。73%的患者接受了尸体全移植物。0.5、1、5、10 和 20 年时的总体移植物和患者存活率分别为：76%、73%、67%、63%、53%和 87%、86%、81%、78%、69%。与 1°-pLTx 相比，再移植受者年龄较大、体型较大、肾功能较差，更有可能在 ICU 中等待 pLTx。1°-pLTx 移植物存活的独立显著预测因素包括体重、移植时代和肾脏替代治疗；对于再移植，热缺血时间和 1°-pLTx 与再移植之间的时间。患者生存的独立显著预测因素是肾功能、机械通气和肝病的病因。