Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK.
Br J Surg. 2021 Dec 17;109(1):79-88. doi: 10.1093/bjs/znab347.
Despite high waiting list mortality rates, concern still exists on the appropriateness of using livers donated after circulatory death (DCD). We compared mortality and graft loss in recipients of livers donated after circulatory or brainstem death (DBD) across two successive time periods.
Observational multinational data from the United Kingdom and Ireland were partitioned into two time periods (2008-2011 and 2012-2016). Cox regression methods were used to estimate hazard ratios (HRs) comparing the impact of periods on post-transplant mortality and graft failure.
A total of 1176 DCD recipients and 3749 DBD recipients were included. Three-year patient mortality rates decreased markedly from 19.6 per cent in time period 1 to 10.4 per cent in time period 2 (adjusted HR 0.43, 95 per cent c.i. 0.30 to 0.62; P < 0.001) for DCD recipients but only decreased from 12.8 to 11.3 per cent (adjusted HR 0.96, 95 per cent c.i. 0.78 to 1.19; P = 0.732) in DBD recipients (P for interaction = 0.001). No time period-specific improvements in 3-year graft failure were observed for DCD (adjusted HR 0.80, 95% c.i. 0.61 to 1.05; P = 0.116) or DBD recipients (adjusted HR 0.95, 95% c.i. 0.79 to 1.14; P = 0.607). A slight increase in retransplantation rates occurred between time period 1 and 2 in those who received a DCD liver (from 7.3 to 11.8 per cent; P = 0.042), but there was no change in those receiving a DBD liver (from 4.9 to 4.5 per cent; P = 0.365). In time period 2, no difference in mortality rates between those receiving a DCD liver and those receiving a DBD liver was observed (adjusted HR 0.78, 95% c.i. 0.56 to 1.09; P = 0.142).
Mortality rates more than halved in recipients of a DCD liver over a decade and eventually compared similarly to mortality rates in recipients of a DBD liver. Regions with high waiting list mortality may mitigate this by use of DCD livers.
尽管候补者死亡率居高不下，但人们仍然对使用死后循环（DCD）捐献的肝脏是否恰当存在担忧。我们比较了两个连续时间段内接受死后循环或脑干死亡（DBD）捐献肝脏的受者的死亡率和移植物丢失率。
从英国和爱尔兰的多中心观察性数据中划分出两个时间段（2008-2011 年和 2012-2016 年）。使用 Cox 回归方法估计时间段对移植后死亡率和移植物衰竭的影响的风险比（HR）。
共纳入 1176 例 DCD 受者和 3749 例 DBD 受者。DCD 受者的 3 年患者死亡率从第 1 个时间段的 19.6%显著下降至第 2 个时间段的 10.4%（校正 HR 0.43，95%置信区间 0.30 至 0.62；P<0.001），而 DBD 受者的死亡率仅从 12.8%下降至 11.3%（校正 HR 0.96，95%置信区间 0.78 至 1.19；P=0.732）（P 交互=0.001）。在 DCD（校正 HR 0.80，95%置信区间 0.61 至 1.05；P=0.116）或 DBD 受者（校正 HR 0.95，95%置信区间 0.79 至 1.14；P=0.607）中均未观察到 3 年移植物衰竭有任何特定时间段的改善。在第 1 个时间段和第 2 个时间段之间，接受 DCD 肝脏的患者的再移植率略有上升（从 7.3%升至 11.8%；P=0.042），但接受 DBD 肝脏的患者无变化（从 4.9%降至 4.5%；P=0.365）。在第 2 个时间段，接受 DCD 肝脏的患者与接受 DBD 肝脏的患者的死亡率无差异（校正 HR 0.78，95%置信区间 0.56 至 1.09；P=0.142）。
10 多年来，DCD 肝脏受者的死亡率下降了一半以上，最终与 DBD 肝脏受者的死亡率相当。候补者死亡率较高的地区可能通过使用 DCD 肝脏来减轻这种情况。
