Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, PA.
Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA.
Liver Transpl. 2018 Jun;24(6):803-809. doi: 10.1002/lt.25048.
Recent data have suggested that pediatric patients wait-listed for a liver transplantation frequently have liver offers declined. However, factors associated with liver offer decisions and center-level variability in practice patterns have not been explored. We evaluated United Network for Organ Sharing data on all match runs from May 1, 2007 to December 31, 2015 in which the liver was offered to ≥1 pediatric patient; the transplant recipient was ranked in the first 40 positions for the organ offer; and the donor was brain-dead and <50 years of age. We used multilevel mixed effects models to evaluate factors associated with organ offer acceptance, among-center variability, and the association between center-level acceptance and wait-list mortality. There were 4088 unique pediatric patients during the study period, comprising 27,094 match runs. Initial Model for End-Stage Liver Disease or Pediatric End-Stage Liver Disease score, history of exception points, recipient region, rank on match run, and geographic share type were all associated with probability of offer acceptance. There was significant among-center variation (P < 0.001) in adjusted liver offer acceptance rates, accounting for donor, recipient, and match-related factors (adjusted acceptance rates: median, 8.9%; range, 5.1%-14.6%). Center-level acceptance rates were associated with wait-list mortality, with a >10% increase in the risk of wait-list mortality for every 1% decrease in a center's adjusted liver offer acceptance rate (odds ratio, 1.10; 95% confidence interval, 1.01-1.19). In conclusion, there is significant among-center variability in liver offer acceptance rates for pediatric patients that is not explained by donor and recipient factors. A center's liver acceptance behavior significantly impacts whether a pediatric patient will be transplanted or die on the waiting list. Liver Transplantation 24 803-809 2018 AASLD.
最近的数据表明，等待肝移植的儿科患者经常会被拒绝提供肝脏。然而，与肝脏提供决策相关的因素以及中心实践模式的差异尚未得到探索。我们评估了 2007 年 5 月 1 日至 2015 年 12 月 31 日期间所有匹配运行的器官共享联合网络数据，其中肝脏提供给≥1 名儿科患者；移植受者在器官提供的前 40 位排名中；供体脑死亡且年龄<50 岁。我们使用多级混合效应模型评估了与器官提供接受率、中心间差异以及中心接受率与等待名单死亡率之间关联相关的因素。在研究期间，有 4088 名独特的儿科患者，包括 27094 次匹配运行。初始终末期肝病模型或儿科终末期肝病评分、例外点史、受者区域、匹配运行中的排名以及地理共享类型均与提供接受率的概率相关。在调整了供体、受者和匹配相关因素后，调整后的肝脏提供接受率存在显著的中心间差异（P<0.001）（调整后的接受率：中位数为 8.9%；范围为 5.1%-14.6%）。中心接受率与等待名单死亡率相关，中心调整后的肝脏接受率每降低 1%，等待名单死亡率的风险增加超过 10%（比值比，1.10；95%置信区间，1.01-1.19）。结论：儿科患者肝脏提供接受率存在显著的中心间差异，无法用供体和受体因素来解释。中心的肝脏接受行为显著影响儿科患者是否会在等待名单上接受移植或死亡。肝脏移植 24 803-809 2018 AASLD。
