Department of Surgery, The University of Hong Kong, Hong Kong, China.
Department of Surgery, Queen Mary Hospital, Hong Kong, China.
Hepatology. 2021 Jun;73(6):2441-2454. doi: 10.1002/hep.31584. Epub 2021 May 4.
Previous recommendations suggested living donor liver transplantation (LDLT) should not be considered for patients with Model for End-Stage Liver Disease (MELD) > 25 and hepatorenal syndrome (HRS).
Patients who were listed with MELD > 25 from 2008 to 2017 were analyzed with intention-to-treat (ITT) basis retrospectively. Patients who had a potential live donor were analyzed as ITT-LDLT, whereas those who had none belonged to ITT-deceased donor liver transplantation (DDLT) group. ITT-overall survival (OS) was analyzed from the time of listing. Three hundred twenty-five patients were listed (ITT-LDLT n = 212, ITT-DDLT n = 113). The risk of delist/death was lower in the ITT-LDLT group (43.4% vs. 19.8%, P < 0.001), whereas the transplant rate was higher in the ITT-LDLT group (78.3% vs. 52.2%, P < 0.001). The 5-year ITT-OS was superior in the ITT-LDLT group (72.6% vs. 49.5%, P < 0.001) for patients with MELD > 25 and patients with both MELD > 25 and HRS (56% vs. 33.8%, P < 0.001). Waitlist mortality was the highest early after listing, and the distinct alteration of slope at survival curve showed that the benefits of ITT-LDLT occurred within the first month after listing. Perioperative outcomes and 5-year patient survival were comparable for patients with MELD > 25 (88% vs. 85.4%, P = 0.279) and patients with both MELD > 25 and HRS (77% vs. 76.4%, P = 0.701) after LDLT and DDLT, respectively. The LDLT group has a higher rate of renal recovery by 1 month (77.4% vs. 59.1%, P = 0.003) and 3 months (86.1% vs, 74.5%, P = 0.029), whereas the long-term estimated glomerular filtration rate (eGFR) was similar between the 2 groups. ITT-LDLT reduced the hazard of mortality (hazard ratio = 0.387-0.552) across all MELD strata.
The ITT-LDLT reduced waitlist mortality and allowed an earlier access to transplant. LDLT in patients with high MELD/HRS was feasible, and they had similar perioperative outcomes and better renal recovery, whereas the long-term survival and eGFR were comparable with DDLT. LDLT should be considered for patients with high MELD/HRS, and the application of LDLT should not be restricted with a MELD cutoff.
先前的建议认为，对于终末期肝病模型（MELD）评分>25 和肝肾综合征（HRS）的患者，不应该考虑进行活体肝移植（LDLT）。
回顾性地对 2008 年至 2017 年 MELD 评分>25 的患者进行意向治疗（ITT）分析。有潜在活体供者的患者作为 ITT-LDLT 进行分析，而没有供者的患者属于 ITT-尸体供肝移植（DDLT）组。从列入名单之日起分析 ITT 总生存（OS）。共有 325 名患者被列入名单（ITT-LDLT n=212，ITT-DDLT n=113）。ITT-LDLT 组的失访/死亡风险较低（43.4%比 19.8%，P<0.001），而 ITT-LDLT 组的移植率较高（78.3%比 52.2%，P<0.001）。对于 MELD>25 的患者和 MELD>25 且合并 HRS 的患者，ITT-LDLT 组的 5 年 ITT-OS 更优（72.6%比 49.5%，P<0.001）。等待名单死亡率在列入名单后早期最高，生存曲线斜率的明显变化表明，ITT-LDLT 的益处发生在列入名单后的第一个月内。MELD>25（88%比 85.4%，P=0.279）和 MELD>25 合并 HRS（77%比 76.4%，P=0.701）患者在 LDLT 和 DDLT 后 5 年的患者生存率相似。LDLT 组术后 1 个月（77.4%比 59.1%，P=0.003）和 3 个月（86.1%比 74.5%，P=0.029）的肾脏恢复率更高，而两组的长期估计肾小球滤过率（eGFR）相似。ITT-LDLT 降低了所有 MELD 分层的死亡率风险（风险比为 0.387-0.552）。
ITT-LDLT 降低了等待名单死亡率，并允许更早地进行移植。对于 MELD/HRS 较高的患者，LDLT 是可行的，他们具有相似的围手术期结局和更好的肾脏恢复，而长期生存和 eGFR 与 DDLT 相当。对于 MELD/HRS 较高的患者，应考虑 LDLT，并且不应该以 MELD 截断值来限制 LDLT 的应用。
