Mazur Rafal D, Cron David C, Chang David C, Yeh Heidi, Dageforde Leigh Anne D
Harvard Medical School, Boston, MA.
Department of Surgery, Massachusetts General Hospital, Boston, MA.
Transplantation. 2024 Jan 1;108(1):204-214. doi: 10.1097/TP.0000000000004621. Epub 2023 Dec 13.
Patients with hepatocellular carcinoma (HCC) have been overprioritized in the deceased donor liver allocation system. The United Network for Organ Sharing adopted a policy in May 2019 that limited HCC exception points to the median Model for End-Stage Liver Disease at transplant in the listing region minus 3. We hypothesized this policy change would increase the likelihood to transplant marginal quality livers into HCC patients.
This was a retrospective cohort study of a national transplant registry, including adult deceased donor liver transplant recipients with and without HCC from May 18, 2017, to May 18, 2019 (prepolicy) to May 19, 2019, to March 1, 2021 (postpolicy). Transplanted livers were considered of marginal quality if they met ≥1 of the following: (1) donation after circulatory death, (2) donor age ≥70, (3) macrosteatosis ≥30% and (4) donor risk index ≥95th percentile. We compared characteristics across policy periods and by HCC status.
A total of 23 164 patients were included (11 339 prepolicy and 11 825 postpolicy), 22.7% of whom received HCC exception points (prepolicy versus postpolicy: 26.1% versus 19.4%; P = 0.03). The percentage of transplanted donor livers meeting marginal quality criteria decreased for non-HCC (17.3% versus 16.0%; P < 0.001) but increased for HCC (17.7% versus 19.4%; P < 0.001) prepolicy versus postpolicy. After adjusting for recipient characteristics, HCC recipients had 28% higher odds of being transplanted with marginal quality liver independent of policy period (odds ratio: 1.28; confidence interval, 1.09-1.50; P < 0.01).
The median Model for End-Stage Liver Disease at transplant in the listing region minus 3 policy limited exception points and decreased the quality of livers received by HCC patients.
在已故供体肝脏分配系统中，肝细胞癌（HCC）患者一直被过度优先考虑。器官共享联合网络于2019年5月采用了一项政策，将HCC例外点数限制为登记地区移植时终末期肝病模型中位数减去3。我们假设这一政策变化会增加将边缘质量肝脏移植给HCC患者的可能性。
这是一项对国家移植登记处的回顾性队列研究，包括2017年5月18日至2019年5月18日（政策实施前）以及2019年5月19日至2021年3月1日（政策实施后）接受和未接受HCC的成年已故供体肝脏移植受者。如果移植肝脏符合以下至少一项标准，则被认为质量边缘：（1）循环死亡后捐赠；（2）供体年龄≥70岁；（3）大脂肪变性≥30%；（4）供体风险指数≥第95百分位数。我们比较了不同政策时期以及有无HCC情况下的特征。
共纳入23164例患者（政策实施前11339例，政策实施后11825例），其中22.7%的患者获得HCC例外点数（政策实施前与政策实施后：26.1%对19.4%；P = 0.03）。符合边缘质量标准的移植供体肝脏百分比在非HCC患者中有所下降（17.3%对16.0%；P < 0.001），但在HCC患者中有所增加（17.7%对19.4%；P < 0.001），政策实施前与政策实施后相比。在调整受者特征后，无论政策时期如何，HCC受者接受边缘质量肝脏移植的几率高28%（优势比：1.28；置信区间，1.09 - 1.50；P <
登记地区移植时终末期肝病模型中位数减去3的政策限制了例外点数，并降低了HCC患者接受肝脏的质量。
