School of Medicine, University of Edinburgh, Edinburgh, UK.
Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK.
Lancet Healthy Longev. 2024 May;5(5):e346-e355. doi: 10.1016/S2666-7568(24)00044-8.
Following the introduction of an algorithm aiming to maximise life-years gained from liver transplantation in the UK (the transplant benefit score [TBS]), donor livers were redirected from younger to older patients, mortality rate equalised across the age range and short-term waiting list mortality reduced. Understanding age-related prioritisation has been challenging, especially for younger patients and clinicians allocating non-TBS-directed livers. We aimed to assess age-related prioritisation within the TBS algorithm by modelling liver transplantation prioritisation based on data from a UK transplant unit and comparing these data with other regions.
In this population-based modelling study, serum parameters and age at liver transplantation assessment of patients attending the Scottish Liver Transplant Unit, Edinburgh, UK, between December, 2002, and November, 2023, were combined with representative synthetic data to model TBS survival predictions, which were compared according to age group (25-49 years vs ≥60 years), chronic liver disease severity, and disease cause. Models for end-stage liver disease (UKELD [UK], MELD [Eurotransplant region], and MELD 3.0 [USA]) were used as validated comparators of liver disease severity.
Of 2093 patients with chronic liver disease, 1808 (86%) had complete datasets and liver disease parameters consistent with eligibility for the liver transplant waiting list in the UK (UKELD ≥49). Disease severity as assessed by UKELD, MELD, and MELD 3.0 did not differ by age (median UKELD scores of 56 for patients aged ≥60 years vs 56 for patients aged 25-49 years; MELD scores of 16 vs 16; and MELD 3.0 scores of 18 vs 18). TBS increased with advancing age (R=0·45, p<0·0001). TBS predicted that transplantation in patients aged 60 years or older would provide a two-fold greater net benefit at 5 years than in patients aged 25-49 years (median TBS 1317 [IQR 1116-1436] in older patients vs 706 [411-1095] in younger patients; p<0·0001). Older patients were predicted to have shorter survival without transplantation than younger patients (263 days [IQR 144-473] in older patients vs 861 days [448-1164] in younger patients; p<0·0001) but similar survival after transplantation (1599 days [1563-1628] vs 1573 days [1525-1614]; p<0·0001). Older patients could reach a TBS for which a liver offer was likely below minimum criteria for transplantation (UKELD <49), whereas many younger patients were required to have high-urgent disease (UKELD >60). US and Eurotransplant programmes did not prioritise according to age.
The UK liver allocation algorithm prioritises older patients for transplantation by predicting that advancing age increases the benefit from liver transplantation. Restricted follow-up and biases in waiting list data might limit the accuracy of these benefit predictions. Measures beyond overall waiting list mortality are required to fully capture the benefits of liver transplantation.
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在英国引入了一种旨在从肝移植中获得最大生命年数的算法（移植获益评分[TBS]）后，供肝从年轻患者转向老年患者，年龄范围内的死亡率均等化，短期等待名单死亡率降低。理解与年龄相关的优先排序一直具有挑战性，尤其是对于年轻患者和分配非 TBS 定向肝脏的临床医生。我们旨在通过基于英国移植单位的数据对 TBS 算法中的年龄相关优先排序进行建模，并将这些数据与其他地区进行比较，从而评估 TBS 算法中的年龄相关优先排序。
在这项基于人群的建模研究中，对苏格兰肝脏移植中心（爱丁堡，英国）就诊的患者的血清参数和肝移植评估时的年龄进行了组合，并结合了代表性的合成数据，以对 TBS 生存预测进行建模，根据年龄组（25-49 岁与≥60 岁）、慢性肝病严重程度和疾病原因对这些数据进行了比较。终末期肝病模型（英国ELD[UK]、欧洲移植区域 MELD[MELD]和美国 MELD 3.0[MELD 3.0]）被用作验证性的肝病严重程度比较器。
在 2093 名患有慢性肝病的患者中，1808 名（86%）具有完整的数据集和符合英国肝移植等待名单资格的肝脏疾病参数（英国ELD≥49）。年龄对英国ELD、MELD 和 MELD 3.0 评估的疾病严重程度没有影响（年龄≥60 岁的患者的英国ELD 中位数为 56，年龄为 25-49 岁的患者为 56；MELD 中位数为 16，MELD 3.0 中位数为 18）。TBS 随着年龄的增长而增加（R=0.45，p<0.0001）。TBS 预测，与 25-49 岁的患者相比，60 岁或以上的患者在 5 年内的移植将提供两倍的净收益（老年患者的中位 TBS 为 1317[IQR 1116-1436]，年轻患者为 706[411-1095]；p<0.0001）。与年轻患者相比，老年患者在未接受移植的情况下预计存活时间更短（老年患者为 263 天[IQR 144-473]，年轻患者为 861 天[448-1164]；p<0.0001），但在接受移植后的存活时间相似（老年患者为 1599 天[1563-1628]，年轻患者为 1573 天[1525-1614]；p<0.0001）。老年患者可能达到 TBS，这意味着肝脏供应可能低于移植的最低标准（英国ELD<49），而许多年轻患者则需要高紧急疾病（英国ELD>60）。美国和欧洲移植项目没有根据年龄进行优先排序。
英国肝脏分配算法通过预测年龄的增加会增加肝移植的获益，从而优先考虑老年患者进行移植。随访受限和等待名单数据中的偏差可能会限制这些获益预测的准确性。需要采取超越总体等待名单死亡率的措施，以充分捕获肝移植的益处。
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