Baylor University Medical Center, Dallas, TX, United States.
Baylor University Medical Center, Dallas, TX, United States.
J Hepatol. 2018 Jul;69(1):43-50. doi: 10.1016/j.jhep.2018.02.004. Epub 2018 Feb 15.
Over the last decade, liver transplantation of sicker, older non-hepatitis C cirrhotics with multiple co-morbidities has increased in the United States. We sought to identify an easily applicable set of recipient factors among HCV negative adult transplant recipients associated with significant morbidity and mortality within five years after liver transplantation.
We collected national (n = 31,829, 2002-2015) and center-specific data. Coefficients of relevant recipient factors were converted to weighted points and scaled from 0-5. Recipient factors associated with graft failure included: ventilator support (five patients; hazard ratio [HR] 1.59; 95% CI 1.48-1.72); recipient age >60 years (three patients; HR 1.29; 95% CI 1.23-1.36); hemodialysis (three patients; HR 1.26; 95% CI 1.16-1.37); diabetes (two patients; HR 1.20; 95% CI 1.14-1.27); or serum creatinine ≥1.5 mg/dl without hemodialysis (two patients; HR 1.15; 95% CI 1.09-1.22).
Graft survival within five years based on points (any combination) was 77.2% (0-4), 69.1% (5-8) and 57.9% (>8). In recipients with >8 points, graft survival was 42% (model for end-stage liver disease [MELD] score <25) and 50% (MELD score 25-35) in recipients receiving grafts from donors with a donor risk index >1.7. In center-specific data within the first year, subjects with ≥5 points (vs. 0-4) had longer hospitalization (11 vs. 8 days, p <0.01), higher admissions for rehabilitation (12.3% vs. 2.7%, p <0.01), and higher incidence of cardiac disease (14.2% vs. 5.3%, p <0.01) and stage 3 chronic kidney disease (78.6% vs. 39.5%, p = 0.03) within five years.
The impact of co-morbidities in an MELD-based organ allocation system need to be reassessed. The proposed clinical tool may be helpful for center-specific assessment of risk of graft failure in non-HCV patients and for discussion regarding relevant morbidity in selected subsets.
Over the last decade, liver transplantation of sicker, older patient with multiple co-morbidities has increased. In this study, we show that a set of recipient factors (recipient age >60 years, ventilator status, diabetes, hemodialysis and creatinine >1.5 mg/dl) can help identify patients that may not do well after transplant. Transplanting sicker organs in patients with certain combinations of these characteristics leads to lower survival.
在过去十年中，美国进行了更多患有非丙型肝炎肝硬化且合并多种合并症的病情较重、年龄较大的患者的肝移植。我们试图确定一组 HCV 阴性成年肝移植受者中易于应用的受者因素，这些因素与肝移植后五年内的显著发病率和死亡率相关。
我们收集了全国（n=31829，2002-2015 年）和中心特定的数据。相关受者因素的系数转换为加权点，并按 0-5 进行缩放。与移植物失功相关的受者因素包括：呼吸机支持（5 例；危险比 [HR] 1.59；95%CI 1.48-1.72）；受者年龄>60 岁（3 例；HR 1.29；95%CI 1.23-1.36）；血液透析（3 例；HR 1.26；95%CI 1.16-1.37）；糖尿病（2 例；HR 1.20；95%CI 1.14-1.27）；或血清肌酐≥1.5mg/dl 而无血液透析（2 例；HR 1.15；95%CI 1.09-1.22）。
根据积分（任何组合），五年内移植物存活率为 77.2%（0-4）、69.1%（5-8）和 57.9%（>8）。在>8 分的受者中，移植受体的 MELD 评分<25 时，移植物存活率为 42%（模型终末期肝病评分 [MELD]），MELD 评分 25-35 时为 50%（MELD 评分 25-35），受体接受供体风险指数>1.7 的供体。在中心特定的第一年数据中，与 0-4 分相比，积分≥5 分（vs. 0-4）的患者住院时间更长（11 天 vs. 8 天，p<0.01），康复住院率更高（12.3% vs. 2.7%，p<0.01），心脏病（14.2% vs. 5.3%，p<0.01）和 3 期慢性肾脏病（78.6% vs. 39.5%，p=0.03）的发病率更高在五年内。
在基于 MELD 的器官分配系统中，需要重新评估合并症的影响。所提出的临床工具可能有助于对非 HCV 患者的中心特定风险评估移植物失功，并有助于讨论选定亚组的相关发病率。
在过去十年中，患有多种合并症的病情较重、年龄较大的患者的肝移植有所增加。在这项研究中，我们表明，一组受者因素（受者年龄>60 岁、呼吸机状态、糖尿病、血液透析和肌酐>1.5mg/dl）可以帮助识别移植后可能预后不良的患者。在某些特征组合的患者中移植病情较重的器官会导致存活率降低。
