Ho K S, Lashner B A, Emond J C, Baker A L
Liver Study Unit, University of Chicago Medical Center, Illinois 60637.
Hepatology. 1993 Jul;18(1):66-72.
Prior variceal bleeding may adversely affect the prognosis of orthotopic liver transplantation. We studied this question by evaluating all 175 adult patients undergoing orthotopic liver transplantation at our institution to determine risk factors associated with mortality after transplantation. Seventy patients demonstrated prior variceal bleeding, and of those, 32 had a course of sclerotherapy. Thirteen also had portal systemic shunts. Compared with the 105 transplant patients who had no prior bleeding, patients who bled were more likely to have parenchymal liver disease (74% vs. 50%), equally likely to have cholestatic liver disease (19%), and less likely to have malignancy (6% vs. 19%) or fulminant liver failure (1% vs. 12%). Bleeding patients also were more likely to be Child-Pugh class C (46% vs. 35%). By the common closing date of December 31, 1990, 26 patients (37%) with prior bleeding and 48 patients (46%) without bleeding died after transplantation. From survival curves, patients with prior bleeding had improved survival rates at 1 yr (65% vs. 54%), at 3 yr (60% vs. 47%) and at 5 yr (55% vs. 43%), although the differences were not statistically significant. With a proportional hazards model to adjust for confounding effects, the relative risk of mortality among patients with prior bleeding was 0.60 (95% confidence interval, 0.27 to 1.30). Sclerotherapy or portal systemic shunts did not alter survival. Important adverse risk factors for mortality included older age at transplantation, black race, malignant disease and more advanced Child-Pugh class. This study suggests that prior esophageal variceal bleeding did not adversely affect the mortality of patients undergoing orthotopic liver transplantation.
既往静脉曲张出血可能会对原位肝移植的预后产生不利影响。我们通过评估在我院接受原位肝移植的所有175例成年患者来研究这个问题，以确定与移植后死亡率相关的危险因素。70例患者有既往静脉曲张出血，其中32例接受过硬化治疗疗程。13例还有门体分流。与105例无既往出血的移植患者相比，有出血的患者更可能患有实质性肝病（74%对50%），患胆汁淤积性肝病的可能性相同（19%），患恶性肿瘤（6%对19%）或暴发性肝衰竭（1%对12%）的可能性较小。出血患者也更可能属于Child-Pugh C级（46%对35%）。到1990年12月31日这个共同截止日期时，26例（37%）有既往出血的患者和48例（46%）无出血的患者在移植后死亡。从生存曲线来看，有既往出血的患者在1年（65%对54%）、3年（60%对47%）和5年（55%对43%）时的生存率有所提高，尽管差异无统计学意义。采用比例风险模型来调整混杂效应，有既往出血的患者死亡的相对风险为0.60（95%置信区间，0.27至1.30）。硬化治疗或门体分流并未改变生存率。死亡率的重要不良危险因素包括移植时年龄较大、黑人种族、恶性疾病以及Child-Pugh分级更高级别。这项研究表明，既往食管静脉曲张出血并未对接受原位肝移植患者的死亡率产生不利影响。
