Multi-Organ Transplant Program, University Health Network Toronto, Ontario, Canada; Department of Surgery, Henry Ford Hospital, Detroit, Michigan, USA; Department of Surgical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden; Deparment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Institute of Liver Studies, Kings College Hospital, Denmark Hill, London, UK.
J Hepatol. 2022 Dec;77(6):1607-1618. doi: 10.1016/j.jhep.2022.07.035. Epub 2022 Sep 25.
BACKGROUND & AIMS: Adult-to-adult living donor liver transplantation (LDLT) offers an opportunity to decrease the liver transplant waitlist and reduce waitlist mortality. We sought to compare donor and recipient characteristics and post-transplant outcomes after LDLT in the US, the UK, and Canada.
This is a retrospective multicenter cohort-study of adults (≥18-years) who underwent primary LDLT between Jan-2008 and Dec-2018 from three national liver transplantation registries: United Network for Organ Sharing (US), National Health Service Blood and Transplantation (UK), and the Canadian Organ Replacement Registry (Canada). Patients undergoing retransplantation or multi-organ transplantation were excluded. Post-transplant survival was evaluated using the Kaplan-Meier method, and multivariable adjustments were performed using Cox proportional-hazards models with mixed-effect modeling.
A total of 2,954 living donor liver transplants were performed (US: n = 2,328; Canada: n = 529; UK: n = 97). Canada has maintained the highest proportion of LDLT utilization over time (proportion of LDLT in 2008 - US: 3.3%; Canada: 19.5%; UK: 1.7%; p <0.001 - in 2018 - US: 5.0%; Canada: 13.6%; UK: 0.4%; p <0.001). The 1-, 5-, and 10-year patient survival was 92.6%, 82.8%, and 70.0% in the US vs. 96.1%, 89.9%, and 82.2% in Canada vs. 91.4%, 85.4%, and 66.7% in the UK. After adjustment for characteristics of donors, recipients, transplant year, and treating transplant center as a random effect, all countries had a non-statistically significantly different mortality hazard post-LDLT (Ref US: Canada hazard ratio 0.53, 95% CI 0.28-1.01, p = 0.05; UK hazard ratio 1.09, 95% CI 0.59-2.02, p = 0.78).
The use of LDLT has remained low in the US, the UK and Canada. Despite this, long-term survival is excellent. Continued efforts to increase LDLT utilization in these countries may be warranted due to the growing waitlist and differences in allocation that may disadvantage patients currently awaiting liver transplantation.
This multicenter international comparative analysis of living donor liver transplantation in the United States, the United Kingdom, and Canada demonstrates that despite low use of the procedure, the long-term outcomes are excellent. In addition, the mortality risk is not statistically significantly different between the evaluated countries. However, the incidence and risk of retransplantation differs between the countries, being the highest in the United Kingdom and lowest in the United States.
成人对成人活体肝移植（LDLT）为减少肝移植等候名单和降低等候名单死亡率提供了机会。我们旨在比较美国、英国和加拿大 LDLT 后供体和受者的特征及移植后结局。
这是一项回顾性多中心队列研究，纳入了 2008 年 1 月至 2018 年 12 月期间，三个国家肝移植注册中心（美国器官共享联合网络、英国国民保健署血液与移植中心和加拿大器官替换登记处）报告的原发性 LDLT 成年（≥18 岁）患者。排除再次肝移植或多器官移植患者。采用 Kaplan-Meier 法评估移植后生存情况，采用混合效应模型的 Cox 比例风险模型进行多变量调整。
共进行了 2954 例活体供肝肝移植（美国：n=2328；加拿大：n=529；英国：n=97）。加拿大一直保持着较高的 LDLT 使用率（2008 年比例-美国：3.3%；加拿大：19.5%；英国：1.7%；p<0.001-2018 年比例-美国：5.0%；加拿大：13.6%；英国：0.4%；p<0.001）。美国患者的 1、5、10 年生存率分别为 92.6%、82.8%和 70.0%，加拿大分别为 96.1%、89.9%和 82.2%，英国分别为 91.4%、85.4%和 66.7%。在调整供体、受者、移植年份和治疗移植中心的特征作为随机效应后，所有国家 LDLT 后死亡率的风险无统计学差异（美国为参照，加拿大的风险比为 0.53，95%CI 0.28-1.01，p=0.05；英国的风险比为 1.09，95%CI 0.59-2.02，p=0.78）。
美国、英国和加拿大的 LDLT 使用率一直较低。尽管如此，长期生存率仍非常好。由于等候名单不断增加以及分配差异可能使目前等待肝移植的患者处于不利地位，这些国家可能需要继续努力增加 LDLT 的使用率。
这项在美国、英国和加拿大进行的多中心国际活体肝移植比较分析表明，尽管 LDLT 的使用率较低，但长期结果良好。此外，评估的国家之间死亡率风险无统计学显著差异。然而，各国之间的再移植发生率和风险不同，英国最高，美国最低。
