Zhang Suyanpeng, Suen Sze-Chuan, Gong Cynthia L, Pham Jessica, Trebicka Jonel, Duvoux Christophe, Klein Andrew S, Wu Tiffany, Jalan Rajiv, Sundaram Vinay
Daniel J. Epstein Department of Industrial and Systems Engineering, Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA.
Fetal & Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
JHEP Rep. 2021 Sep 23;3(6):100367. doi: 10.1016/j.jhepr.2021.100367. eCollection 2021 Dec.
BACKGROUND & AIMS: Uncertainties exist surrounding the timing of liver transplantation (LT) among patients with acute-on-chronic liver failure grade 3 (ACLF-3), regarding whether to accept a marginal quality donor organ to allow for earlier LT or wait for either an optimal organ offer or improvement in the number of organ failures, in order to increase post-LT survival.
We created a Markov decision process model to determine the optimal timing of LT among patients with ACLF-3 within 7 days of listing, to maximize overall 1-year survival probability.
We analyzed 6 groups of candidates with ACLF-3: patients age ≤60 or >60 years, patients with 3 organ failures alone or 4-6 organ failures, and hepatic or extrahepatic ACLF-3. Among all groups, LT yielded significantly greater overall survival probability . remaining on the waiting list for even 1 additional day ( <0.001), regardless of organ quality. Creation of 2-way sensitivity analyses, with variation in the probability of receiving an optimal organ and expected post-transplant mortality, indicated that overall survival is maximized by earlier LT, particularly among candidates >60 years old or with 4-6 organ failures. The probability of improvement from ACLF-3 to ACLF-2 does not influence these recommendations, as the likelihood of organ recovery was less than 10%.
During the first week after listing for patients with ACLF-3, earlier LT in general is favored over waiting for an optimal quality donor organ or for recovery of organ failures, with the understanding that the analysis is limited to consideration of only these 3 variables.
In the setting of grade 3 acute-on-chronic liver failure (ACLF-3), questions remain regarding the timing of transplantation in terms of whether to proceed with liver transplantation with a marginal donor organ or to wait for an optimal liver, and whether to transplant a patient with ACLF-3 or wait until improvement to ACLF-2. In this study, we used a Markov decision process model to demonstrate that earlier transplantation of patients listed with ACLF-3 maximizes overall survival, as opposed to waiting for an optimal donor organ or for improvement in the number of organ failures.
对于慢性肝功能衰竭急性加重3级（ACLF-3）患者肝移植（LT）的时机，存在不确定性，即是否接受边缘质量的供体器官以实现更早的肝移植，还是等待最佳器官供体或器官衰竭数量改善，以提高肝移植后的生存率。
我们创建了一个马尔可夫决策过程模型，以确定在列入名单7天内的ACLF-3患者中肝移植的最佳时机，从而使总体1年生存概率最大化。
我们分析了6组ACLF-3候选者：年龄≤60岁或>60岁的患者、仅出现3个器官衰竭或4-6个器官衰竭的患者，以及肝性或肝外性ACLF-3患者。在所有组中，无论器官质量如何，进行肝移植的总体生存概率显著高于在等待名单上再多等1天（P<0.001）。进行双向敏感性分析，改变接受最佳器官的概率和预期移植后死亡率，结果表明更早进行肝移植可使总体生存率最大化，尤其是在年龄>60岁或有4-6个器官衰竭的候选者中。从ACLF-3改善为ACLF-2的概率并不影响这些建议，因为器官恢复的可能性小于10%。
对于ACLF-3患者，在列入名单后的第一周内，一般而言，更早进行肝移植优于等待最佳质量的供体器官或器官衰竭恢复，需理解该分析仅限于考虑这三个变量。
在慢性肝功能衰竭急性加重3级（ACLF-3）的情况下，关于移植时机仍存在问题，即是否使用边缘供体器官进行肝移植或等待最佳肝脏，以及是否对ACLF-3患者进行移植或等待改善为ACLF-2。在本研究中，我们使用马尔可夫决策过程模型证明，与等待最佳供体器官或器官衰竭数量改善相比，ACLF-3列入名单的患者更早进行移植可使总体生存率最大化。
