Brahmania Mayur, Sachar Yashasavi, Arab Juan Pablo, Khan Mohammad Qasim, Bhati Piali, Onizuka Kristyne, Teriaky Anouar, Qumosani Karim, McClure Andrew, Welk Blayne, Lam Melody, Tang Ephraim, Skaro Anton, Rahman Adam
University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.
Division of Gastroenterology & Hepatology, Department of Medicine, Western University, London, Ontario, Canada.
Am J Gastroenterol. 2025 Jul 2. doi: 10.14309/ajg.0000000000003628.
Decompensated cirrhosis has a median survival of 2 years without liver transplantation (LT). This study investigates whether distance from LT center affects waitlist mortality and receipt of LT.
The study population was generated from the transplant database in London, Ontario, Canada. Adult patients on the waitlist for LT between January 1, 2012, and December 31, 2021, were included. Data were linked to the Institute for Clinical Evaluative Sciences to examine clinically relevant outcomes, using ≤150 km vs >150 km to stratify descriptive analysis. Multivariate time-to-event analyses were conducted to evaluate the hazards of increasing distance from LT center on waitlist mortality and receipt of LT.
Of the 552 patients meeting study criteria, 394 (71.4%) received LT in an overall predominantly male cohort (n = 390, 70%), with a median age of 59 years (interquartile range [IQR] 52-64) and median distance from the LT center of 110 km (IQR 59-191). There were no significant differences between patients living ≤150 km (n = 362) vs >150 km (n = 190) from the LT center. In liver disease etiology-alcohol-related liver disease remained the most common (32.9% vs 33.2%; P = 0.95) across both categories, with no difference in median Model for End Stage Liver Disease-Sodium scores between those who did and did not receive transplant (17 [IQR 9-25] vs 18 [IQR 10-27]; P = 0.12). On multivariable analysis, distance to the LT center did not affect receipt of LT, waitlist mortality, or postlisting ED visits and hospitalizations. Model for End-Stage Liver Disease-Sodium at listing was a significant predictor of increased waitlist mortality (hazard ratio 1.12; confidence interval 1.09-1.16; P < 0.01), whereas hepatocellular carcinoma diagnosis was associated with reduced waitlist mortality (hazard ratio 0.13; confidence interval 0.04-0.45; P < 0.01). Patients further from the LT center had a higher median number of hospitalizations (2 vs 1; P = 0.02) and emergency department (ED) visits (3 vs 2; P < 0.01) in the year before LT listing, and significantly ED utilization within 90 days postlisting (0 [IQR 0-2] vs 0 [IQR 0-1]; P < 0.05), albeit this was not consistent on multivariable analysis.
Geographical distance does not significantly affect LT waitlist mortality or receipt of LT. However, differences in healthcare utilization suggest disparities may still manifest with a negative impact on patients in the pre-LT setting.
失代偿期肝硬化患者若不进行肝移植（LT），其平均生存期为2年。本研究旨在调查与肝移植中心的距离是否会影响等待名单上的死亡率以及肝移植的接受情况。
研究人群来自加拿大安大略省伦敦市的移植数据库。纳入2012年1月1日至2021年12月31日期间在等待肝移植名单上的成年患者。数据与临床评估科学研究所相关联，以检查临床相关结果，使用≤150公里与>150公里对描述性分析进行分层。进行多变量事件发生时间分析，以评估距离肝移植中心距离增加对等待名单上的死亡率和肝移植接受情况的风险。
在符合研究标准的552例患者中，394例（71.4%）接受了肝移植，总体上以男性为主（n = 390，70%），中位年龄为59岁（四分位间距[IQR] 52 - 64），距肝移植中心的中位距离为110公里（IQR 59 - 191）。距离肝移植中心≤150公里（n = 362）和>150公里（n = 190）的患者之间无显著差异。在肝病病因方面，酒精性肝病在两类患者中仍然是最常见的（32.9%对33.2%；P = 0.95），接受移植和未接受移植患者的终末期肝病 - 钠模型评分中位数无差异（17 [IQR 9 - 25]对18 [IQR 10 - 27]；P = 0.12）。多变量分析显示，距离肝移植中心并不影响肝移植的接受情况、等待名单上的死亡率或列入名单后的急诊就诊和住院情况。列入名单时的终末期肝病 - 钠模型是等待名单上死亡率增加的显著预测因素（风险比1.12；置信区间1.09 - 1.16；P < 0.01），而肝细胞癌诊断与等待名单上死亡率降低相关（风险比0.13；置信区间0.04 - 0.45；P < 0.01）。距离肝移植中心较远的患者在列入肝移植名单前一年的住院中位数较高（2次对1次；P = 0.02），急诊就诊次数较多（3次对2次；P < 0.01），且列入名单后90天内急诊利用率显著较高（0 [IQR 0 - 2]对0 [IQR 0 - 1]；P < 0.05），尽管在多变量分析中这不具有一致性。
地理距离不会显著影响肝移植等待名单上的死亡率或肝移植的接受情况。然而，医疗保健利用方面的差异表明，在肝移植前阶段，差异可能仍然存在，并对患者产生负面影响。
