Scorecard and Insights From Approaches to Liver Allocation Around the World
Scorecard and Insights From Approaches to Liver Allocation Around the World
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DOI：
10.1002/lt.24631
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发表时间：
2016-11-01
影响因子：
4.6
通讯作者：
Clavien, Pierre A.
中科院分区：
文献类型：
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作者：
Dutkowski, Phillip;Clavien, Pierre A.
根据终末期肝病模型（MELD）评分的估计，资源供应的稀缺已经引发了几个国家根据医疗需求分配肝脏移植物。这一决定是基于MELD在预测等待名单死亡率方面的优势，与之前的Child-Turcotte-Pugh评分或其他肝硬化评分相比，可以进行简单和更客观的评估。(1)自2002年以来，MELD连续被美国器官共享联合网络（UNOS）采用，用于优先考虑美国的肝移植候选人，其次是北意大利移植（2006），欧洲移植（2006），加拿大（2004-2006），法国（2007），瑞士（2007），波兰，匈牙利，斯洛伐克和捷克共和国。在欧洲以外，MELD分配也用于以色列和南美洲，例如巴西和阿根廷。值得注意的是，等待时间仅适用于评分相同的患者，MELD通常上限为40，因为所有处于该水平或更高水平的患者都显示出相当高的死亡率。(1)相比之下，中心分配政策在欧洲其他地区仍然更受欢迎，最好是在捐赠率较高的国家，如西班牙，葡萄牙，Scanditransplant，英国，土耳其，罗马尼亚，Balttransplant，可以自由地将移植物用于假定的“最佳”受体，除了考虑等待时间。虽然MELD政策导致更少的患者被列为原位肝移植（奥尔特）而且等待名单上的死亡人数也减少了，这一概念引起了人们的关注，即器官是否被分配给那些病情严重无法进行肝移植的候选人。(1-3)因此，已经开发了评分来预测无效结果，具有供体和/或受体因素的不同组合，包括MELD，例如D-MELD（由供体年龄3接受者MELD定义），（4）Δ MELD，（5）供体风险指数（DRI），（6）肝移植后存活结果（SOFT），（7）风险平衡（BAR）评分，（3）加州洛杉矶大学无效风险评分（UCLA-FRS），（8）和生存获益分析。（9，10）然而，拒绝肝脏移植候选人的肝脏报价仍然是一个重大挑战。(11)尽管DRI（1.4）和D-MELD（1600）的阈值可能太低，排除了许多移植物或移植候选者（4，6，12），但无效肝移植（7）的SOFT阈值35或40似乎相当高，仅针对美国0.1%-1%的已收载患者（表1）。（3，7）此外，死亡率或移植物丢失率随着大多数评分（如DRI、D-MELD以及SOFT）的增加而线性增加（4），使得难以验证拒绝移植的阈值。目前唯一一个暗示移植后死亡率呈指数增长的模型，
Scarce supply of resources has triggered allocation of liver grafts by medical needs in several countries, as estimated by the Model for End-Stage Liver Disease (MELD) score. This decision was based on the superiority of MELD in terms of prediction of wait-list mortality, compared with the previous Child-Turcotte-Pugh scoring or other scores in liver cirrhosis, and enables simple and more objective assessment.(1) Since 2002, MELD was consecutively adopted by United Network for Organ Sharing (UNOS) for prioritization of liver transplant candidates in the United States, followed by North Italian transplant (2006), Eurotransplant (2006), Canada (2004-2006), France (2007), Switzerland (2007), Poland, Hungary, Slovakia, and Czech Republic. Outside of Europe, MELD allocation is also used in Israel and South America, eg, Brazil and Argentina. Notably, waiting time is applied only for patients with equal score, and MELD is generally capped at 40, as all patients at this level or higher disclosed comparable high mortality.(1) In contrast, a center allocation policy remains more popular in other parts of Europe, preferably in countries with higher donation rates, such as Spain, Portugal, Scanditransplant, United Kingdom, Turkey, Romania, Balttransplant, with some freedom to use the graft to a presumed “best” recipient, besides considering waiting time.Although MELD policy has resulted in fewer patients being listed for orthotopic liver transplantation (OLT) and also fewer deaths on the waiting list, this concept has raised concerns, whether organs are being distributed to candidates who are too sick for liver transplantation.(1-3) Scores have therefore been developed to predict futile outcome, with varying combinations of donor and/or recipient factors, including MELD, such as D-MELD (defined by donor age 3 recipient MELD),(4) Delta MELD,(5) Donor Risk Index (DRI),(6) Survival Outcome Following Liver Transplantation (SOFT),(7) Balance of Risk (BAR) score,(3) University of California Los Angeles Futility Risk Score (UCLA-FRS),(8) and survival benefit analysis.(9, 10) However, refusing a liver offer for a liver transplant candidate has remained a major challenge.(11) Although the thresholds of DRI (1.4) and D-MELD (1600) are probably too low, with exclusion of many grafts or transplant candidates,(4, 6, 12) the SOFT threshold at 35 or 40 for futile liver transplantation (7) appears rather high, targeting only 0.1%-1% of listed patients in the United States (Table 1).(3, 7) Furthermore, mortality or graft loss increase linearly with increasing points in most scores, such as DRI, D-MELD, and also SOFT (4) making validation of a threshold to deny transplantation difficult. The only model that implicates currently an exponential increase in posttransplant mortality with