地点和分配：欧洲严重急性慢性肝衰竭患者接受肝移植的机会不平等。
Location and allocation: Inequity of access to liver transplantation for patients with severe acute-on-chronic liver failure in Europe.
机构信息
Service de Réanimation Médicale Hôpital de Hautepierre Strasbourg France Liver Intensive Therapy Unit, Institute of Liver Studies Kings College Hospital London UK Hepatology and Gastroenterology Unit ASST GOM Niguarda Milan Italy Value-Based Healthcare Unit IRCCS Multi Medica Sesto San Giovanni Italy Research Centre on Public Health (CESP) University of Milan-Bicocca Monza Italy AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire Unité INSERM 1193, Université Paris-Saclay Villejuif France Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, Saint Eloi Hospital University of Montpellier France Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit HCL Hôpital de la Croix-Rousse Lyon France Translational Hepatology, Department of Internal Medicine Goethe University Frankfurt Germany European Foundation for the Study of Chronic Liver Failure (EF Clif) Barcelona Spain Liver ICU, Liver Unit, Institute of Digestive and Metabolic Diseases Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd Barcelona Spain School of Medicine and Surgery University of Milano-Bicocca Milan Italy Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine University of Padova Padova Italy Department of General, Visceral and Transplant Surgery University Hospital Tübingen Germany IRCCS Azienda Ospedaliero-Universitaria di Bologna Bologna Italy Gastro-hepatology Unit, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino University of Torino Torino Italy University Medical Center Rotterdam Department of Surgery, Division of HPB and Transplant Surgery Erasmus MC, Transplant Institute Rotterdam the Netherlands Department of General, Transplant and Liver Surgery Medical University of Warsaw Warsaw Poland Division of Abdominal Surgery, Department of Surgery Geneva University Hospitals Geneva Switzerland Hepatology and Liver Transplantation Unit CIBEREHD, Hospital General Universitario Gregorio Marañón, Universidad Complutense Madrid Spain Faculty of Medicine La Fe University Hospital Valencia Spain Gastroenterology Unit Papa Giovanni XXIII Hospital Bergamo Italy Division of Gastroenterology and Hepatology, CRC "A. M. and A. Migliavacca" Center for Liver Disease Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy Hepatology and Gastroenterology Unit ISMETT-IRCCS Palermo Italy European Liver Transplant Registry Centre Hépato-Biliaire Hôpital Universitaire Paul-Brousse Villejuif France Service de Chirurgie Hépato-Biliaire et Transplantation Hépatique Hôpital de Hautepierre Strasbourg France Department of Digestive Surgery and Liver Transplantation, Croix Rousse Hospital, Hospices Civils de Lyon University of Lyon I Lyon France General Surgery and Transplantation Unit ASST GOM Niguarda Milan Italy Department of Anesthesia, Critical Care, ASST GOM Niguarda, School of Medicine and Surgery University of Milano-Bicocca Milan Italy HPB Surgery and Transplantation Hospital Universitario La Paz Madrid Spain Service d'Hepatologie Hôpital Henri Mondor Créteil France Liver Failure Group, Institute for Liver and Digestive Health UCL Medical School London UK.
出版信息
Liver Transpl. 2022 Sep;28(9):1429-1440. doi: 10.1002/lt.26499. Epub 2022 Jun 16.
There is growing evidence that liver transplantation (LT) is the most effective treatment for acute-on-chronic liver failure grade-3 (ACLF-3). This study examines whether and how this evidence translates into practice by analyzing the variability in intensive care unit (ICU) admissions, listing strategies, and LT activity for patients with ACLF-3 across transplantation centers in Europe. Consecutive patients who were admitted to the ICU with ACLF-3, whether or not they were listed and/or transplanted with ACLF-3, between 2018 and 2019 were included across 20 transplantation centers. A total of 351 patients with ACLF-3 were included: 33 had been listed prior to developing ACLF-3 and 318 had not been listed at the time of admission to the ICU. There was no correlation between the number of unlisted patients with ACLF-3 admitted to the ICU and the number listed or transplanted while in ACLF-3 across centers. By contrast, there was a correlation between the number of patients listed and the number transplanted while in ACLF-3. About 21% of patients who were listed while in ACLF-3 died on the waiting list or were delisted. The percentage of LT for patients with ACLF-3 varied from 0% to 29% for those transplanted with decompensated cirrhosis across centers (average = 8%), with an I index of 68% (95% confidence interval, 49%-80%), showing substantial heterogeneity among centers. The 1-year survival for all patients with ACLF-3 was significantly higher in centers that listed and transplanted more patients with ACLF-3 (>10 patients) than in centers that listed and transplanted fewer: 36% versus 20%, respectively (p = 0.012). Patients with ACLF-3 face inequity of access to LT across Europe. Waitlisting strategies for patients with ACLF-3 influence their access to LT and, ultimately, their survival.
越来越多的证据表明，肝移植（LT）是治疗慢性肝衰竭伴急性肝损伤 3 级（ACLF-3）最有效的方法。本研究通过分析欧洲 20 家移植中心 ICU 收治、登记策略和 LT 活动的变异性，探讨了这一证据是否以及如何转化为实践。2018 年至 2019 年期间，连续 351 例 ACLF-3 患者被纳入研究，无论其是否被列入 ACLF-3 登记名单以及/或是否接受过 ACLF-3 移植。其中 33 例在发生 ACLF-3 之前已被列入名单，318 例在入住 ICU 时未被列入名单。入住 ICU 的未登记 ACLF-3 患者人数与中心登记或移植 ACLF-3 患者人数之间没有相关性。相比之下，登记患者人数与移植 ACLF-3 患者人数之间存在相关性。约 21%的登记 ACLF-3 的患者在等待名单上死亡或被取消登记。移植失代偿性肝硬化患者的 LT 比例因中心而异，从 0%到 29%不等（平均为 8%），I 指数为 68%（95%置信区间，49%-80%），显示出中心之间存在很大的异质性。所有 ACLF-3 患者的 1 年生存率在登记和移植更多 ACLF-3 患者（>10 例）的中心显著高于登记和移植较少患者的中心：分别为 36%和 20%（p=0.012）。ACLF-3 患者在欧洲面临着 LT 机会的不平等。登记 ACLF-3 患者的登记策略影响其获得 LT 的机会，最终影响其生存率。
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