Rosen H R, Shackleton C R, Martin P
Division of Gastroenterology and Hepatology, Oregon Health Sciences University, Portland 97207, USA.
Med Clin North Am. 1996 Sep;80(5):1069-102. doi: 10.1016/s0025-7125(05)70480-6.
The tremendous success of OLT as a highly effective treatment for patients with end-stage liver disease has resulted in a rapid increase in the number of candidates for the procedure. Refinements in organ preservation, improvements in surgical technique and immunosuppression, and better postoperative management have contributed to improved survival rates. The discrepancy between the paucity of organs and the increasing numbers of potential recipients will continue to worsen until there are extraordinary breakthroughs in providing alternatives to human whole-organ livers, such as xenografts or cultured hepatocyte infusions. For now, the vast majority of patients with life-threatening liver disease are not likely to receive a liver graft. Thus, the issues of patient selection and timing of OLT have become even more relevant. Prompt referral to a transplant center is not only in the patient's best interest, but also it has been shown to be cost-effective. Over the last 30 years, it has become clear that hepatic malignancy, initially a common reason for OLT, should be an indication for transplantation only in highly selected individuals. The role of adjuvant chemotherapy needs to be defined, and proven treatment alternatives need to be developed. New antiviral agents may enable a large group of patients with chronic hepatitis B to be successfully transplanted, placing even greater demands on the already limited supply of donor livers. Hepatitis B appears to be species specific, and it is conceivable that xenotransplantation from a nonsusceptible donor species may confer protection to HBV reinfection, eliminating the problems of an inadequate donor supply. Until novel approaches, including xenotransplantation, gene therapy, or replacement of hepatic function by cultured hepatocyte infusions, become a widespread reality, future allocation policies may highlight outcome as well as urgency as a fundamental variable to determine if transplantation is reasonable. Survival rates have been shown to fall with advancing levels of urgency, resulting in a conflict between equity and efficacy in organ allocation. As waiting lists for liver transplantation continue to grow, it is becoming increasingly apparent that patients must be referred to a transplant center earlier in the course of liver disease.
肝移植作为终末期肝病患者的一种高效治疗方法取得了巨大成功，这导致该手术候选者数量迅速增加。器官保存技术的改进、手术技术和免疫抑制的改善以及更好的术后管理都有助于提高生存率。在提供人类全肝替代物（如异种移植或培养肝细胞输注）方面取得非凡突破之前，器官稀缺与潜在受者数量不断增加之间的差距将继续恶化。目前，绝大多数患有危及生命的肝病的患者不太可能接受肝移植。因此，肝移植的患者选择和时机问题变得更加重要。及时转诊至移植中心不仅符合患者的最佳利益，而且已被证明具有成本效益。在过去30年中，很明显，肝恶性肿瘤最初是肝移植的常见原因，现在仅应在经过严格挑选的个体中作为移植指征。辅助化疗的作用需要明确，并且需要开发经过验证的替代治疗方法。新型抗病毒药物可能使大量慢性乙型肝炎患者成功接受移植，这对本就有限的供肝供应提出了更高要求。乙型肝炎似乎具有物种特异性，可以想象，来自不易感供体物种的异种移植可能会对乙肝病毒再感染起到保护作用，从而消除供体供应不足的问题。在包括异种移植、基因治疗或通过培养肝细胞输注替代肝功能等新方法成为广泛现实之前，未来的分配政策可能会将结果以及紧迫性作为决定移植是否合理的基本变量加以强调。已表明生存率会随着紧迫性的增加而下降，这导致器官分配中的公平性和有效性之间产生冲突。随着肝移植等待名单的持续增长，越来越明显的是，患者必须在肝病病程的早期就被转诊至移植中心。
