Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA.
Division of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA.
Transplantation. 2021 Dec 1;105(12):2564-2570. doi: 10.1097/TP.0000000000003728.
Survival after living donor liver transplantation (LDLT) in the United States is excellent. However, the significance of pretransplant kidney disease on outcomes in this population is poorly understood.
This was a retrospective cohort study of 2806 LDLT recipients nationally between January 2010 and June 2020. Recipients with estimated glomerular filtration rate <40 mL/min/1.73 m2 (eGFR-low) or requiring dialysis were compared. Multivariable survival analyses evaluated (1) eGFR-low as a predictor of post-LDLT survival and (2) the survival of LDLT versus deceased donor liver transplant (DDLT) alone with eGFR-low.
From 2010 to 2020, 140 (5.0%) patients had eGFR-low and 18 (0.6%) required dialysis pre-LDLT. The number of LDLTs requiring dialysis between 2017 and 2020 outnumbered the prior 7 y. Overall LDLT experience was greater at centers performing LDLT in recipients with renal dysfunction (P < 0.001). LDLT recipients with eGFR-low had longstanding renal dysfunction: mean eGFR 3-6 mo before LDLT 42.7 (±15.1) mL/min/1.73 m2. Nearly half (5/12) of eGFR-low recipients with active kidney transplant (KT) listing at LDLT experienced renal recovery. Five patients underwent early KT after LDLT via the new "safety net" policy. Unadjusted survival after LDLT was worse with eGFR-low (hazard ratio 2.12 versus eGFR ≥40 mL/min/1.73 m2; 95% confidence interval, 1.47-3.05; P < 0.001), but no longer so when accounting for mean eGFR 3-6 mo pre-LDLT (hazard ratio, 1.27; 95% confidence interval, 0.82-1.95; P = 0.3). The adjusted survival of patients with eGFR-low receiving LDLT versus deceased donor liver transplant alone was not different (P = 0.08).
Overall, outcomes after LDLT with advanced renal dysfunction are acceptable. These findings are relevant given the recent "safety net" KT policy.
在美国，活体供肝移植（LDLT）后的存活率非常高。然而，在该人群中，移植前肾病对结局的意义尚不清楚。
这是一项回顾性队列研究，纳入了 2010 年 1 月至 2020 年 6 月期间全国范围内的 2806 例 LDLT 受者。比较肾小球滤过率<40mL/min/1.73m2（eGFR-低）或需要透析的受者。多变量生存分析评估了（1）eGFR-低作为 LDLT 后生存的预测因素，以及（2）LDLT 与单独接受 deceased donor liver transplant（DDLT）且伴有 eGFR-低的生存情况。
2010 年至 2020 年期间，140 例（5.0%）患者的 eGFR-低，18 例（0.6%）在 LDLT 前需要透析。2017 年至 2020 年期间，需要透析的 LDLT 数量超过了前 7 年。在肾功能障碍的 LDLT 受者中进行 LDLT 的中心经验更多（P<0.001）。eGFR-低的 LDLT 受者存在长期肾功能障碍：LDLT 前 3-6 个月的平均 eGFR 为 42.7（±15.1）mL/min/1.73m2。近一半（5/12）eGFR-低且有活动性肾移植（KT）名单的受者在 LDLT 时经历了肾功能恢复。5 例患者通过新的“安全网”政策在 LDLT 后早期接受了 KT。未经调整的 LDLT 后生存率在 eGFR-低时较差（风险比 2.12，95%置信区间为 1.47-3.05；P<0.001），但在考虑 LDLT 前 3-6 个月的平均 eGFR 后不再如此（风险比 1.27，95%置信区间为 0.82-1.95；P=0.3）。eGFR-低的患者接受 LDLT 与单独接受 DDLT 的调整后生存率无差异（P=0.08）。
总体而言，伴有晚期肾功能障碍的 LDLT 后的结局是可以接受的。鉴于最近的“安全网”KT 政策，这些发现具有重要意义。
