Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD, 21201, USA.
Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA.
Dig Dis Sci. 2024 Sep;69(9):3513-3553. doi: 10.1007/s10620-024-08522-6. Epub 2024 Jul 16.
Pre-liver transplant (LT) functional status is an important determinant of prognosis post LT. There is insufficient data on how functional status affects outcomes of transplant recipients based on the specific etiology of liver disease. We stratified LT recipients by etiology of liver disease to evaluate the effects of functional status on post-LT prognosis in each subgroup.
2005-2019 United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research (STAR) was used to select patients with liver transplant. A total of 14,290 patients were included in the analysis. These patients were stratified by functional status according to Karnofsky Performance Scale (KPS) score: no assistance, some assistance, or total assistance. They were then further divided into six diagnosis categories: metabolic dysfunction-associated steatotic liver disease (MASLD), hereditary disorders, hepatitis C, hepatitis B, autoimmune disease (AID), and alcoholic liver disease (ALD). Primary endpoints included all-cause mortality and graft failure, while secondary endpoints included organ-specific causes of death. Those under the age of 18 and those with non-whole liver or prior liver transplantation were excluded.
Patients with MASLD requiring some assistance (aHR: 1.57, 95% CI 1.03-2.39, p = 0.04) and those requiring total assistance (aHR: 2.32, 95% CI 1.48-3.64, p < 0.001) had higher incidences of graft failure compared to those requiring no assistance. Those with MASLD requiring total assistance had a higher all-cause mortality rate than those needing no assistance (aHR: 1.62, 95% CI 1.38-1.89, p < 0.001). Patients with hereditary causes of liver disease showed a lower incidence of all-cause mortality in recipients needing some assistance compared with those needing no assistance (aHR: 0.52, 95% CI 0.34-0.80, p = 0.003). LT recipients with hepatitis C, AID, and ALD all showed higher incidences of all-cause mortality in the total assistance cohort when compared to the no assistance cohort. For the secondary endpoints of specific cause of death, transplant recipients with MASLD needing total assistance had higher rates of death due to general cardiac causes, graft rejection, general infectious causes, sepsis, general renal causes, and general respiratory causes.
Patients with MASLD cirrhosis demonstrated the worst overall outcomes, suggesting that this population may be particularly vulnerable. Poor functional status in patients with end-stage liver disease from hepatitis B or hereditary disease was not associated with a significantly increased rate of adverse outcomes, suggesting that the KPS score may not be broadly applicable to all patients awaiting LT.
肝移植前（LT）的功能状态是 LT 后预后的重要决定因素。根据肝病的具体病因，关于功能状态如何影响移植受者的结局的数据还不够充分。我们根据肝病的病因对 LT 受者进行分层，以评估功能状态对每个亚组 LT 后预后的影响。
使用 2005 年至 2019 年美国器官共享联合网络（UNOS）标准移植分析和研究（STAR）数据库选择接受肝移植的患者。共纳入 14290 例患者。根据卡诺夫斯基表现量表（KPS）评分，这些患者按功能状态分为无辅助、部分辅助和完全辅助。然后，他们进一步分为六个诊断类别：代谢功能障碍相关脂肪性肝病（MASLD）、遗传性疾病、丙型肝炎、乙型肝炎、自身免疫性疾病（AID）和酒精性肝病（ALD）。主要终点包括全因死亡率和移植物失功，次要终点包括器官特异性死亡原因。排除年龄<18 岁和非全肝或既往肝移植的患者。
需要部分辅助的 MASLD 患者（aHR：1.57，95%CI 1.03-2.39，p=0.04）和需要完全辅助的 MASLD 患者（aHR：2.32，95%CI 1.48-3.64，p<0.001）移植物失功发生率高于不需要辅助的患者。需要完全辅助的 MASLD 患者全因死亡率高于不需要辅助的患者（aHR：1.62，95%CI 1.38-1.89，p<0.001）。遗传性肝病患者需要部分辅助的患者全因死亡率低于不需要辅助的患者（aHR：0.52，95%CI 0.34-0.80，p=0.003）。丙型肝炎、AID 和 ALD 的 LT 受者在完全辅助组的全因死亡率均高于无辅助组。对于特定死亡原因的次要终点，需要完全辅助的 MASLD 移植受者因一般心脏原因、移植物排斥、一般感染原因、败血症、一般肾脏原因和一般呼吸原因导致的死亡率更高。
MASLD 肝硬化患者的总体预后最差，表明该人群可能特别脆弱。乙型肝炎或遗传性疾病终末期肝病患者的功能状态较差与不良结局发生率的显著增加无关，这表明 KPS 评分可能不适用于所有等待 LT 的患者。
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