Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada.
Department of General Surgery, University of Toronto, Toronto, ON, Canada.
Transplantation. 2019 Oct;103(10):2136-2143. doi: 10.1097/TP.0000000000002616.
There is a lack of information about survival after dropout from the liver transplant waiting list. Therefore, we aimed to assess the overall survival, and risk factors for death, after waiting list dropout due to hepatocellular carcinoma (HCC) progression.
We assessed patients who dropped out of the liver transplant waiting list between 2000 and 2016 in a single, large academic North American center. Patients were divided into 3 groups according to the types of HCC progression: locally advanced disease (LAD), extrahepatic disease (EHD), and macrovascular invasion (MVI). The primary outcome was overall survival. Survival was assessed by the Kaplan-Meier method. Predictors of death after dropout were assessed by multivariable Cox regression.
During the study period, 172 patients dropped out due to HCC progression. Of those, 37 (21.5%), 74 (43%), and 61 (35.5%) dropped out due to LAD, EHD, and MVI, respectively. Median survival according to cause of dropout (LAD, EHD, or MVI) was 1.0, 4.4, or 3.3 months, respectively (P = 0.01). Model for End-stage Liver Disease (MELD) score (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.01-1.08), alcoholic liver disease (HR, 1.66; 95% CI, 1.02-2.71), and α-fetoprotein >1000 ng/mL (HR, 1.86; 95% CI, 1.22-2.84) were predictors of mortality after dropout. Dropout due to EHD (HR, 0.61; 95% CI, 0.38-0.98) and undergoing treatment after dropout were protective factors (HR, 0.32; 95% CI, 0.21-0.48) for death.
Patient prognosis after dropout is dismal. However, a subgroup of patients may have longer survival. The present study identifies the patterns of waitlist dropout in patients with HCC and provides evidence for the effectiveness of treatment strategies offered to HCC patients after dropout.
由于缺乏关于肝癌进展后从肝移植等待名单中退出的生存信息，因此，我们旨在评估因肝细胞癌（HCC）进展而从等待名单中退出后的总体生存率和死亡风险因素。
我们评估了 2000 年至 2016 年期间在单一大型北美学术中心从肝移植等待名单中退出的患者。根据 HCC 进展的类型，患者分为 3 组：局部进展性疾病（LAD）、肝外疾病（EHD）和大血管侵犯（MVI）。主要结局是总生存率。通过 Kaplan-Meier 法评估生存率。通过多变量 Cox 回归评估退出后死亡的预测因素。
在研究期间，由于 HCC 进展，172 名患者退出。其中，37 名（21.5%）、74 名（43%）和 61 名（35.5%）分别因 LAD、EHD 和 MVI 而退出。根据退出原因（LAD、EHD 或 MVI）的中位生存时间分别为 1.0、4.4 或 3.3 个月（P = 0.01）。终末期肝病模型（MELD）评分（风险比[HR]，1.04；95%置信区间[CI]，1.01-1.08）、酒精性肝病（HR，1.66；95%CI，1.02-2.71）和α-胎蛋白>1000ng/mL（HR，1.86；95%CI，1.22-2.84）是退出后死亡的预测因素。EHD 导致的退出（HR，0.61；95%CI，0.38-0.98）和退出后的治疗是死亡的保护因素（HR，0.32；95%CI，0.21-0.48）。
患者退出后的预后不佳。然而，有一小部分患者可能有更长的生存时间。本研究确定了 HCC 患者从等待名单中退出的模式，并为 HCC 患者退出后提供治疗策略的有效性提供了证据。
