美国肝移植新实践的传播模式。

The Spread Pattern of New Practice in Liver Transplantation in the United States.

机构信息

Division of Abdominal Transplant, Department of Surgery, Stanford University Medical Center, Stanford, California, USA.

Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California, USA.

出版信息

Clin Transplant. 2024 Jul;38(7):e15379. doi: 10.1111/ctr.15379.

DOI:10.1111/ctr.15379

PMID:38952196

Abstract

BACKGROUND

Introducing new liver transplantation (LT) practices, like unconventional donor use, incurs higher costs, making evaluation of their prognostic justification crucial. This study reexamines the spread pattern of new LT practices and its prognosis across the United States.

METHODS

The study investigated the spread pattern of new practices using the UNOS database (2014-2023). Practices included LT for hepatitis B/C (HBV/HCV) nonviremic recipients with viremic donors, LT for COVID-19-positive recipients, and LT using onsite machine perfusion (OMP). One year post-LT patient and graft survival were also evaluated.

RESULTS

LTs using HBV/HCV donors were common in the East, while LTs for COVID-19 recipients and those using OMP started predominantly in California, Arizona, Texas, and the Northeast. K-means cluster analysis identified three adoption groups: facilities with rapid, slow, and minimal adoption rates. Rapid adoption occurred mainly in high-volume centers, followed by a gradual increase in middle-volume centers, with little increase in low-volume centers. The current spread patterns did not significantly affect patient survival. Specifically, for LTs with HCV donors or COVID-19 recipients, patient and graft survivals in the rapid-increasing group was comparable to others. In LTs involving OMP, the rapid- or slow-increasing groups tended to have better patient survival (p = 0.05) and significantly improved graft survival rates (p = 0.02). Facilities adopting new practices often overlap across different practices.

DISCUSSION

Our analysis revealed three distinct adoption groups across all practices, correlating the adoption aggressiveness with LT volume in centers. Aggressive adoption of new practices did not compromise patient and graft survivals, supporting the current strategy. Understanding historical trends could predict the rise in future LT cases with new practices, aiding in resource distribution.

摘要

背景

引入新的肝移植（LT）实践，如非常规供体的使用，会增加成本，因此评估其预后合理性至关重要。本研究重新考察了新的 LT 实践在美国的传播模式及其预后。

方法

本研究使用 UNOS 数据库（2014-2023 年）调查了新实践的传播模式。这些实践包括使用病毒血症供体为 HBV/HCV 非病毒血症受者进行 LT、为 COVID-19 阳性受者进行 LT 以及使用现场机器灌注（OMP）进行 LT。还评估了 LT 后 1 年患者和移植物的存活率。

结果

在东部，HBV/HCV 供体的 LT 很常见，而 COVID-19 受者的 LT 和使用 OMP 的 LT 主要在加利福尼亚、亚利桑那、德克萨斯和东北部开始。K-均值聚类分析确定了三个采用群体：快速、缓慢和最小采用率的设施。快速采用主要发生在大容量中心，随后中容量中心逐渐增加，小容量中心增加很少。目前的传播模式并没有显著影响患者的存活率。具体来说，对于使用 HCV 供体或 COVID-19 受者的 LT，快速增加组的患者和移植物存活率与其他组相当。在涉及 OMP 的 LT 中，快速或缓慢增加组的患者存活率较好（p=0.05），移植物存活率显著提高（p=0.02）。采用新实践的机构往往在不同的实践中重叠。