Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Division of Gastroenterology, Hepatology, and Nutrition, and Vanderbilt University Medical Center, Nashville, Tennessee, USA.
J Palliat Med. 2022 Sep;25(9):1404-1408. doi: 10.1089/jpm.2021.0403. Epub 2022 Mar 25.
End-stage liver disease (ESLD) is associated with high morbidity and mortality, with liver transplantation as the only existing cure. Despite reduced quality of life and limited life expectancy, referral to palliative care (PC) rarely occurs. Moreover, there is scarcity of data on the appropriate timing and type of PC intervention needed. To evaluate PC utilization and documentation in ESLD patients declined or delisted for transplant at a tertiary care medical center with a large liver transplantation program. We performed a retrospective cohort study of all patients discussed in Liver Transplant Committee (LTC) at our academic medical center between August 2018 and May 2020 in the United States. Patients declined or delisted for liver transplantation were included. Baseline demographics, model for end-stage liver disease (MELD) score, decompensation events, and reason for transplant ineligibility were recorded. The primary outcome was PC referral. Secondary outcomes included survival from LTC decision, time from LTC decision to PC referral, and code status in relation to PC referral. Of 769 patients discussed at LTC, 135 were declined for transplantation. Thirty-seven (27%) received referral to PC. When adjusting for body mass index and age, MELD score of 21-30 had odds ratio (OR) of 4.5 (95% confidence interval [CI]: 1.7-12.3) and MELD score >30 had OR of 12.8 (95% CI: 3.9-47.7) for PC referral when compared with MELD score <20. When adjusting for MELD score, presence of ascites had OR of 4.6 (95% CI: 1.1-19.1) and presence of multiple complications had OR of 2.2 (95% CI: 2.2-3.8). Only 37 (27%) patients delisted or declined for liver transplantation were referred to PC. MELD score and degree of decompensation were important factors associated with referral. Continued exploration of these data could help guide future studies and help determine timing and criteria for PC referral.
终末期肝病 (ESLD) 与高发病率和死亡率相关，肝移植是唯一的治愈方法。尽管生活质量降低且预期寿命有限，但很少向姑息治疗 (PC) 转诊。此外，关于需要的 PC 干预的适当时间和类型的数据稀缺。
为了评估在一家拥有大型肝移植项目的三级保健医疗中心中，在 LTC 讨论后被拒绝或取消肝移植资格的 ESLD 患者的 PC 使用情况和记录情况。我们对 2018 年 8 月至 2020 年 5 月在美国学术医疗中心的 LTC 讨论的所有患者进行了回顾性队列研究。纳入被拒绝或取消肝移植资格的患者。记录了基线人口统计学资料、终末期肝病模型 (MELD) 评分、失代偿事件以及移植不合格的原因。主要结局是 PC 转诊。次要结局包括从 LTC 决策到 PC 转诊的生存时间、从 LTC 决策到 PC 转诊的时间以及与 PC 转诊相关的代码状态。
在 LTC 讨论的 769 名患者中，有 135 名被拒绝进行移植。37 名（27%）患者接受了 PC 转诊。当按体重指数和年龄调整时，MELD 评分 21-30 的比值比（OR）为 4.5（95%置信区间 [CI]：1.7-12.3），MELD 评分>30 的 OR 为 12.8（95%CI：3.9-47.7），与 MELD 评分<20 相比，PC 转诊的可能性更高。当按 MELD 评分调整时，腹水的存在的 OR 为 4.6（95%CI：1.1-19.1），多种并发症的存在的 OR 为 2.2（95%CI：2.2-3.8）。
只有 37 名（27%）被取消或拒绝进行肝移植的患者被转诊至 PC。MELD 评分和失代偿程度是与转诊相关的重要因素。进一步探讨这些数据可以帮助指导未来的研究，并有助于确定 PC 转诊的时间和标准。
