Okumura Kenji, Dhand Abhay, Misawa Ryosuke, Sogawa Hiroshi, Veillette Gregory, Nishida Seigo
Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA.
J Clin Exp Hepatol. 2024 Mar-Apr;14(2):101296. doi: 10.1016/j.jceh.2023.10.007. Epub 2023 Oct 21.
New deceased donor liver allocation policy using an acuity circle (AC)-based model was implemented on February 4th, 2020. The effect of AC policy on simultaneous liver-kidney transplantation (SLKT) remains unknown. The aim of this study was to assess the effect of AC policy on SLKT waitlist mortality, transplant probability, and post-transplant outcomes.
Using the United Network for Organ Sharing database, 4908 adult SLKT candidates during two study periods, pre-AC (Aug-2017 to Feb-2020, N = 2770) and post-AC (Feb-2020 to Dec-2021, N = 2138) were analyzed. Outcomes included 90-day waitlist mortality, transplant probability, and post-transplant patient and graft survival.
Compared to pre-AC period, SLKT recipients during post-AC period had higher median model for end-stage liver disease (MELD) score (24 vs 23, < 0.001), and less percentage of MELD exception (4.6% vs 7.7%, = 0.001). The 90-day waitlist mortality was same, but the probability of SLKT increased in post-AC period ( < 0.001). Post-AC period also saw increased utilization of donation after cardiac death organs (11% vs 6.4%, < 0.001) and decreased rates of transplantation among Black candidates (7.9% vs 13%). After risk adjustment, post-AC period was not associated with any significant difference in 90-day waitlist mortality (sub-distribution hazard ratio [sHR] 0.80; 95% CI 0.56-1.16, = 0.24), and a higher 90-day probability of SLKT (sHR 1.68; 95% CI 1.41-1.99, < 0.001). During post-transplant period, one-year patient survival, liver and kidney graft survival were comparable between two study periods.
The AC liver allocation policy was associated with increased transplant probability of adult SLKT candidates without decreasing waitlist mortality, post-transplant patient survival, or liver and kidney graft survival.
基于急性病圈（AC）模型的新型已故供体肝脏分配政策于2020年2月4日实施。AC政策对肝肾联合移植（SLKT）的影响尚不清楚。本研究的目的是评估AC政策对SLKT等待名单死亡率、移植概率和移植后结局的影响。
利用器官共享联合网络数据库，分析了两个研究期间的4908名成年SLKT候选人，即AC政策实施前（2017年8月至2020年2月，N = 2770）和AC政策实施后（2020年2月至2021年12月，N = 2138）。结局包括90天等待名单死亡率、移植概率以及移植后患者和移植物存活率。
与AC政策实施前相比，AC政策实施后的SLKT受者终末期肝病模型（MELD）评分中位数更高（24对23，P < 0.001），MELD例外情况的百分比更低（4.6%对7.7%，P = 0.001）。90天等待名单死亡率相同，但AC政策实施后SLKT的概率增加（P < 0.001）。AC政策实施后，心脏死亡后器官捐赠的利用率也有所提高（11%对6.4%，P < 0.001），黑人候选人的移植率下降（7.9%对13%）。经过风险调整后，AC政策实施后90天等待名单死亡率无显著差异（亚分布风险比[sHR] 0.80；95%置信区间0.56 - 1.16，P = 0.24），而SLKT的90天概率更高（sHR 1.68；95%置信区间1.41 - 1.99，P < 0.001）。在移植后期间，两个研究期间的1年患者存活率、肝脏和肾脏移植物存活率相当。
AC肝脏分配政策与成年SLKT候选人移植概率增加相关，且不降低等待名单死亡率、移植后患者存活率或肝脏和肾脏移植物存活率。
