Song E, Fabian J, Boshoff P E, Maher H, Gaylard P, Bentley A, Hale M J, Ngwenya S P, Etheredge H, Mahomed A, Bobat B, Strobele B, Loveland J, Britz R, Botha J F
Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa; Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
S Afr Med J. 2018 Oct 26;108(11):929-936. doi: 10.7196/SAMJ.2018.v108i11.13286.
Liver transplantation is the standard of care for the treatment of liver failure worldwide, yet millions of people living in sub-Saharan Africa remain without access to these services. South Africa (SA) has two liver transplant centres, one in Cape Town and the other in Johannesburg, where Wits Donald Gordon Medical Centre (WDGMC) started an adult liver transplant programme in 2004.
To describe the outcomes of the adult liver transplant programme at WDGMC.
This was a retrospective review of all adult orthotopic liver transplants performed at WDGMC from 16 August 2004 to 30 June 2016 with a minimum follow-up of 6 months. The primary outcome was recipient and graft survival and the effect of covariates on survival. Kaplan-Meier survival analysis included all adults who underwent their first transplant for end-stage liver disease (ESLD) (N=275). Proportional hazards regression analysis using hazard ratios (HRs) was conducted to determine which covariates were associated with a significantly increased risk of mortality.
A total of 297 deceased-donor liver transplants were performed during the study period; 19/297 (6.4%) were for acute liver failure (ALF) and the remainder were for ESLD. The median age of recipients was 51 years (interquartile range 41 - 59), and two-thirds were male. The most common cause of ESLD was primary sclerosing cholangitis. The median follow-up was 3.2 years, and recipient survival was characterised in the following intervals: 90 days = 87.6% (95% confidence interval (CI) 83.1 - 91.0), 1 year = 81.7% (95% CI 76.6 - 85.8), and 5 years = 71.0% (95% CI 64.5 - 76.5). Allograft survival was similar: 90 days = 85.8% (95% CI 81.1 - 89.4), 1 year = 81.0% (95% CI 75.8 - 85.2), and 5 years = 69.1% (95% CI 62.6 - 74.7). The most significant covariates that impacted on mortality were postoperative biliary leaks (HR 2.0 (95% CI 1.05 - 3.80)), recipient age >60 years at time of transplant (HR 2.06 (95% CI 1.06 - 3.99)), theatre time >8 hours (HR 3.13 (95% CI 1.79 - 5.48)), and hepatic artery thrombosis (HR 5.58 (95% CI 3.09 - 10.08)). The most common infectious cause of death was invasive fungal infection.
This study demonstrates that outcomes of the adult orthotopic liver transplant programme at WDGMC are comparable with international transplant centres. Management of biliary complications, early hepatic artery thrombosis and post-transplant infections needs to be improved. Access to liver transplantation services is still extremely limited, but can be improved by addressing the national shortage of deceased donors and establishing a national regulatory body for solid-organ transplantation in SA.
肝移植是全球治疗肝衰竭的标准治疗方法，但撒哈拉以南非洲地区仍有数百万人无法获得这些服务。南非有两个肝移植中心，一个在开普敦，另一个在约翰内斯堡，威特沃特斯兰德大学唐纳德·戈登医疗中心（WDGMC）于2004年启动了成人肝移植项目。
描述WDGMC成人肝移植项目的结果。
这是一项对2004年8月16日至2016年6月30日在WDGMC进行的所有成人原位肝移植的回顾性研究，最低随访时间为6个月。主要结局是受者和移植物存活情况以及协变量对存活的影响。Kaplan-Meier生存分析纳入了所有因终末期肝病（ESLD）接受首次移植的成年人（N=275）。使用风险比（HR）进行比例风险回归分析，以确定哪些协变量与死亡风险显著增加相关。
研究期间共进行了297例尸体供肝移植；19/297（6.4%）为急性肝衰竭（ALF），其余为ESLD。受者的中位年龄为51岁（四分位间距41 - 59岁），三分之二为男性。ESLD最常见的病因是原发性硬化性胆管炎。中位随访时间为3.2年，受者存活情况如下：90天 = 87.6%（95%置信区间（CI）83.1 - 91.0），1年 = 81.7%（95% CI 76.6 - 85.8），5年 = 71.0%（95% CI 64.5 - 76.5）。同种异体移植物存活情况相似：90天 = 85.8%（95% CI 81.1 - 89.4），1年 = 81.0%（95% CI 75.8 - 85.2），5年 = 69.1%（95% CI 62.6 - 74.7）。影响死亡率的最显著协变量是术后胆漏（HR 2.0（95% CI 1.05 - 3.80））、移植时受者年龄>60岁（HR 2.06（95% CI 1.06 - 3.99））、手术时间>8小时（HR 3.13（95% CI 1.79 - 5.48））和肝动脉血栓形成（HR 5.58（95% CI 3.09 - 10.08））。最常见的感染性死亡原因是侵袭性真菌感染。
本研究表明，WDGMC成人原位肝移植项目的结果与国际移植中心相当。胆系并发症、早期肝动脉血栓形成和移植后感染的管理需要改进。肝移植服务的可及性仍然极其有限，但通过解决全国尸体供者短缺问题以及在南非建立一个实体器官移植国家监管机构，可以得到改善。
