Wehrle Chase J, Hong Hanna, Gross Abby, Liu Qiang, Ali Khaled, Cazzaniga Beatrice, Miyazaki Yuki, Tuul Munkhbold, Modaresi Esfeh Jamak, Khalil Mazhar, Pita Alejandro, Fernandes Eduardo, Kim Jaekeun, Diago-Uso Teresa, Aucejo Federico, Kwon David C H, Fujiki Masato, Quintini Cristiano, Schlegel Andrea, Pinna Antonio, Miller Charles, Hashimoto Koji
Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA.
Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA.
Liver Transpl. 2025 Apr 1;31(4):438-449. doi: 10.1097/LVT.0000000000000412. Epub 2024 Jun 5.
Ex situ normothermic machine perfusion (NMP) helps increase the use of extended criteria donor livers. However, the impact of an NMP program on waitlist times and mortality has not been evaluated. Adult patients listed for liver transplant (LT) at 2 academic centers from January 1, 2015, to September 1, 2023, were included (n=2773) to allow all patients ≥6 months follow-up from listing. Routine NMP was implemented on October 14, 2022. Waitlist outcomes were compared from pre-NMP pre-acuity circles (n=1460), pre-NMP with acuity circles (n=842), and with NMP (n=381). Median waitlist time was 79 days (IQR: 20-232 d) at baseline, 49 days (7-182) with acuity circles, and 14 days (5-56) with NMP ( p <0.001). The rate of transplant-per-100-person-years improved from 61-per-100-person-years to 99-per-100-person-years with acuity circles and 194-per-100-person-years with NMP ( p <0.001). Crude mortality without transplant decreased from 18.3% (n=268/1460) to 13.3% (n=112/843), to 6.3% (n=24/381) ( p <0.001) with NMP. The incidence of mortality without LT was 15-per-100-person-years before acuity circles, 19-per-100 with acuity circles, and 9-per-100-person-years after NMP ( p <0.001). Median Model for End-Stage Liver Disease at LT was lowest with NMP, but Model for End-Stage Liver Disease at listing was highest in this era ( p <0.0001). The median donor risk index of transplanted livers at baseline was 1.54 (1.27-1.82), 1.66 (1.42-2.16) with acuity circles, and 2.06 (1.63-2.46) with NMP ( p <0.001). Six-month post-LT survival was not different between eras ( p =0.322). The total cost of health care while waitlisted was lowest in the NMP era ($53,683 vs. $32,687 vs. $23,688, p <0.001); cost-per-day did not differ between eras ( p =0.152). The implementation of a routine NMP program was associated with reduced waitlist time and mortality without compromising short-term survival after liver transplant despite increased use of riskier grafts. Routine NMP use enables better waitlist management with reduced health care costs.
体外常温机器灌注（NMP）有助于增加边缘供肝的利用率。然而，NMP项目对等待名单时间和死亡率的影响尚未得到评估。纳入了2015年1月1日至2023年9月1日期间在2个学术中心登记等待肝移植（LT）的成年患者（n = 2773），以便所有患者从登记起有≥6个月的随访。2022年10月14日实施了常规NMP。比较了NMP前非急性周期（n = 1460）、NMP前有急性周期（n = 842）和NMP实施后（n = 381）的等待名单结果。基线时等待名单的中位时间为79天（IQR：20 - 232天），有急性周期时为49天（7 - 182天），有NMP时为14天（5 - 56天）（p < 0.001）。每100人年的移植率从61/100人年提高到有急性周期时的99/100人年和有NMP时的194/100人年（p < 0.001）。未进行移植的粗死亡率从18.3%（n = 268/1460）降至13.3%（n = 112/843），有NMP时降至6.3%（n = 24/381）（p < 0.001）。未进行LT的死亡率为每100人年15例，有急性周期时为每100人年19例，NMP后为每100人年9例（p < 0.001）。LT时终末期肝病模型中位数在NMP时最低，但登记时终末期肝病模型在这个时期最高（p < 0.0001）。基线时移植肝脏的供体风险指数中位数为1.54（1.27 - 1.82），有急性周期时为1.66（1.42 - 2.16），有NMP时为2.06（1.63 - 2.46）（p < 0.001）。不同时期LT后6个月的生存率无差异（p = 0.322）。等待名单期间的医疗总费用在NMP时代最低（分别为53,683美元、32,687美元和23,688美元，p < 0.001）；不同时期每天的费用无差异（p = 0.152）。常规NMP项目的实施与等待名单时间和死亡率的降低相关，尽管使用了风险更高的移植物，但并未影响肝移植后的短期生存。常规使用NMP能够更好地管理等待名单并降低医疗成本。
