Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI.
Transplantation. 2019 Oct;103(10):2121-2129. doi: 10.1097/TP.0000000000002651.
Status 1A patients are prioritized over liver disease patients regardless of Model for End-stage Liver Disease (MELD) score. We aimed to identify groups with high waitlist mortality in Status 1A and MELD ≥40 patients to determine who would most benefit from transplantation.
Data on patients listed as Status 1A (n = 4447) and MELD ≥40 (n = 3663) over 15 years (2002-2017) was obtained from United Network for Organ Sharing/Organ Procurement and Transplant Network registry. They were divided into 2-derivation and validation groups. Risk factors associated with 28-day waitlist mortality were identified in derivation group and provided risk scores to divide patients into risk groups. Score system was applied to validation group to check its applicability.
Risk factors for waitlist mortality in Status 1A included life support, performance status, severe coagulopathy, severe hypo or hypernatremia, and grade 3-4 encephalopathy. Risk factors in MELD ≥40 included higher MELD scores (≥45), age, sex, race, life support, and encephalopathy. On comparing 7- and 28-day mortality, both were higher in Status 1A and MELD ≥40 high-risk groups compared with low-risk groups in the derivation group (P < 0.001). Probability of transplantation was lowest for high-risk MELD ≥40 patients compared with all other groups (P < 0.001). These findings were reproduced in the validation set. Our proposed risk stratification system also showed acceptable 1-year graft and patient survival in high-risk groups.
Our risk scoring system for extremely ill liver transplant candidates successfully stratified risk of waitlist mortality. Waitlist outcomes might be improved by modifications involving categorization of patients based on the presence/absence of risk factors.
无论终末期肝病模型（MELD）评分如何，状态 1A 患者都优先于肝病患者。我们旨在确定状态 1A 和 MELD≥40 患者中有高等待名单死亡率的群体，以确定谁最受益于移植。
从美国器官共享联合网络/器官获取和移植网络登记处获得了 15 年来（2002-2017 年）列为状态 1A（n=4447）和 MELD≥40（n=3663）的患者数据。他们被分为 2 个推导组和验证组。在推导组中确定与 28 天等待名单死亡率相关的危险因素，并提供风险评分将患者分为风险组。将评分系统应用于验证组，以检查其适用性。
状态 1A 等待名单死亡率的危险因素包括生命支持、表现状态、严重凝血障碍、严重低钠血症或高钠血症和 3-4 级脑病。MELD≥40 的危险因素包括更高的 MELD 评分（≥45）、年龄、性别、种族、生命支持和脑病。在比较 7 天和 28 天死亡率时，推导组中高危状态 1A 和 MELD≥40 组的死亡率均高于低危组（P<0.001）。与所有其他组相比，高危 MELD≥40 患者的移植概率最低（P<0.001）。这些发现也在验证组中得到了复制。我们提出的风险分层系统在高危组中也显示出可接受的 1 年移植物和患者存活率。
我们用于极重症肝移植候选者的风险评分系统成功地对等待名单死亡率的风险进行了分层。通过基于危险因素的有无对患者进行分类的修改，可能会改善等待名单的结果。
