Gayowski T, Marino I R, Singh N, Doyle H, Wagener M, Fung J J, Starzl T E
Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pennsylvania 15213, USA.
Transplantation. 1998 Feb 27;65(4):499-504. doi: 10.1097/00007890-199802270-00008.
One of the most controversial areas in patient selection and donor allocation is the high-risk patient. Risk factors for mortality and major infectious morbidity were prospectively analyzed in consecutive United States veterans undergoing liver transplantation under primary tacrolimus-based immunosuppression.
Twenty-eight pre-liver transplant, operative, and posttransplant risk factors were examined univariately and multivariately in 140 consecutive liver transplants in 130 veterans (98% male; mean age, 47.3 years).
Eighty-two percent of the patients had postnecrotic cirrhosis due to viral hepatitis or ethanol (20% ethanol alone), and only 12% had cholestatic liver disease. Ninety-eight percent of the patients were hospitalized at the time of transplantation (66% United Network for Organ Sharing [UNOS] 2, 32% UNOS 1). Major bacterial infection, posttransplant dialysis, additional immunosuppression, readmission to intensive care unit (P=0.0001 for all), major fungal infection, posttransplant abdominal surgery, posttransplant intensive care unit stay length of stay (P<0.005 for all), donor age, pretransplant dialysis, and creatinine (P<0.05 for all) were significantly associated with mortality by univariate analysis. Underlying liver disease, cytomegalovirus infection and disease, portal vein thrombosis, UNOS status, Childs-Pugh score, patient age, pretransplant bilirubin, ischemia time, and operative blood loss were not significant predictors of mortality. Patients with hepatitis C (HCV) and recurrent HCV had a trend towards higher mortality (P=0.18). By multivariate analysis, donor age, any major infection, additional immunosuppression, posttransplant dialysis, and subsequent transplantation were significant independent predictors of mortality (P<0.05). Major infectious morbidity was associated with HCV recurrence (P=0.003), posttransplant dialysis (P=0.0001), pretransplant creatinine, donor age, median blood loss, intensive care unit length of stay, additional immunosuppression, and biopsy-proven rejection (P<0.05 for all). By multivariate analysis, intensive care unit length of stay and additional immunosuppression were significant independent predictors of infectious morbidity (P<0.03). HCV recurrence was of borderline significance (P=0.07).
Biologic and physiologic parameters appear to be more powerful predictors of mortality and morbidity after liver transplantation. Both donor and recipient variables need to be considered for early and late outcome analysis and risk assessment modeling.
在患者选择和供体分配中最具争议的领域之一是高危患者。对连续接受以他克莫司为主的免疫抑制治疗的美国退伍军人肝移植患者的死亡率和主要感染性发病风险因素进行了前瞻性分析。
对130名退伍军人（98%为男性；平均年龄47.3岁）连续进行的140例肝移植中的28个肝移植前、手术中和移植后的风险因素进行了单因素和多因素检查。
82%的患者因病毒性肝炎或乙醇导致坏死性肝硬化（仅乙醇性肝硬化占20%），只有12%患有胆汁淤积性肝病。98%的患者在移植时住院（66%为器官共享联合网络[UNOS]2级，32%为UNOS 1级）。单因素分析显示，主要细菌感染、移植后透析、额外的免疫抑制、再次入住重症监护病房（所有P=0.0001）、主要真菌感染、移植后腹部手术、移植后重症监护病房住院时间（所有P<0.005）、供体年龄、移植前透析和肌酐（所有P<0.05）与死亡率显著相关。潜在肝病、巨细胞病毒感染和疾病、门静脉血栓形成、UNOS状态、Childs-Pugh评分、患者年龄、移植前胆红素、缺血时间和手术失血量不是死亡率的显著预测因素。丙型肝炎（HCV）患者和复发性HCV患者有较高死亡率的趋势（P=0.18）。多因素分析显示，供体年龄、任何主要感染、额外的免疫抑制、移植后透析和后续移植是死亡率的显著独立预测因素（P<0.05）。主要感染性发病与HCV复发（P=0.003）、移植后透析（P=0.0001）、移植前肌酐、供体年龄、中位失血量、重症监护病房住院时间、额外的免疫抑制和活检证实的排斥反应（所有P<0.05）相关。多因素分析显示，重症监护病房住院时间和额外的免疫抑制是感染性发病的显著独立预测因素（P<0.03）。HCV复发具有临界显著性（P=0.07）。
生物学和生理学参数似乎是肝移植后死亡率和发病率的更强有力预测因素。在早期和晚期结果分析以及风险评估模型中，需要同时考虑供体和受体变量。
