Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada.
Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Hepatol Commun. 2023 Aug 3;7(8). doi: 10.1097/HC9.0000000000000219. eCollection 2023 Aug 1.
Liver transplantation (LT) is frequently lifesaving for people living with primary sclerosing cholangitis (PSC). However, patients are waitlisted for LT according to the model for end-stage liver disease-sodium (MELD-Na) score, which may not accurately reflect the burden of living with PSC. We sought to describe and analyze the clinical trajectory for patients with PSC referred for LT, in a mixed deceased donor/living donor transplant program.
This was a retrospective cohort study from November 2012 to December 2019, including all patients with PSC referred for assessment at the University Health Network Liver Transplant Clinic. Patients who required multiorgan transplant or retransplantation were excluded. Liver symptoms, hepatobiliary malignancy, MELD-Na progression, and death were abstracted from chart review. Competing risk analysis was used for timing of LT, transplant type, and death.
Of 172 PSC patients assessed, 84% (n = 144) were listed of whom 74% were transplanted. Mean age was 47.6 years, and 66% were male. Overall mortality was 18.2% at 2 years. During the follow-up, 16% (n = 23) were removed from the waitlist for infection, clinical deterioration, liver-related mortality or new cancer; 3 had clinical improvement. At listing, 82% (n = 118) had a potential living donor (pLD). Patients with pLD had significantly lower waitlist and liver-related waitlist mortality (HR 0.20, p<0.001 and HR 0.17, p<0.001, respectively), and higher rates of transplantation (HR 1.83, p = 0.05). Exception points were granted to 13/172 (7.5%) patients.
In a high-volume North American LT center, most patients with PSC assessed for transplant were listed and subsequently transplanted. However, this was a consequence of patients engaging in living donor transplantation. Our findings support the concern from patients with PSC that MELD-Na allocation does not adequately address their needs.
肝移植（LT）经常是原发性硬化性胆管炎（PSC）患者的救命疗法。然而，患者根据终末期肝病模型钠（MELD-Na）评分接受 LT 等候名单，这可能无法准确反映 PSC 患者的生活负担。我们试图在一个混合的已故供体/活体供体移植计划中描述和分析接受 LT 评估的 PSC 患者的临床轨迹。
这是一项回顾性队列研究，时间从 2012 年 11 月至 2019 年 12 月，包括所有在多伦多大学健康网络肝移植诊所接受评估的 PSC 患者。排除需要多器官移植或再次移植的患者。从病历回顾中提取肝症状、肝胆恶性肿瘤、MELD-Na 进展和死亡的资料。使用竞争风险分析确定 LT、移植类型和死亡的时间。
在评估的 172 名 PSC 患者中，84%（n=144）列入等候名单，其中 74%接受了移植。平均年龄为 47.6 岁，66%为男性。2 年内总死亡率为 18.2%。在随访期间，16%（n=23）因感染、临床恶化、肝相关死亡率或新发癌症而从等候名单中移除；3 例临床改善。在列入名单时，82%（n=118）有潜在的活体供体（pLD）。有 pLD 的患者等候名单和肝相关等候名单死亡率显著降低（HR 0.20，p<0.001 和 HR 0.17，p<0.001），移植率更高（HR 1.83，p=0.05）。为 172 名患者中的 13 名（7.5%）授予了例外积分。
在北美的一个大容量 LT 中心，大多数接受移植评估的 PSC 患者都被列入名单，随后接受了移植。然而，这是患者参与活体供体移植的结果。我们的发现支持 PSC 患者的担忧，即 MELD-Na 分配不能充分满足他们的需求。
