Outcomes of Early Liver Transplantation for Patients With Severe Alcoholic Hepatitis.
Outcomes of Early Liver Transplantation for Patients With Severe Alcoholic Hepatitis.
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DOI：
10.1053/j.gastro.2018.04.009
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发表时间：
2018-08
期刊：
影响因子：
29.4
通讯作者：
Terrault NA
中科院分区：
文献类型：
--
作者：
Lee BP;Mehta N;Platt L;Gurakar A;Rice JP;Lucey MR;Im GY;Therapondos G;Han H;Victor DW;Fix OK;Dinges L;Dronamraju D;Hsu C;Voigt MD;Rinella ME;Maddur H;Eswaran S;Hause J;Foley D;Ghobrial RM;Dodge JL;Li Z;Terrault NA
美国酒精性肝炎早期肝移植联盟由来自 8 个联合器官共享网络地区的 12 个中心组成，研究严重酒精性肝炎 (AH) 患者的早期肝移植 (LT)（无规定的清醒期）。我们分析了这些患者的结果。我们对 2006 年至 2017 年期间在 12 个中心连续诊断出严重 AH、之前未诊断出肝病或 AH 发作、在戒酒 6 个月前接受 LT 的患者进行了一项回顾性研究。我们收集了有关基线特征、心理社会概况、LT 前的饮酒水平、病程和治疗以及 LT 结局的数据。戒酒间隔定义为最后一次饮酒与 LT 日期之间的时间。主要结局是 LT 后的生存率和饮酒情况，定义为滑倒或持续。在147名接受肝移植的AH患者中，LT前的中位禁欲时间为55天； 54% 的患者因 AH 接受皮质类固醇治疗，患者的中位 Lille 评分为 0.82，终末期肝病钠模型评分中位为 39。LT 后患者的累积生存率在 1 年时为 94%（95% 置信区间 [CI]，89%–97%），在 3 年时为 84%（95% CI，75%–90%）。 LT 出院后，72% 的人戒酒，18% 的人出现酒精中毒，11% 的人持续饮酒。 LT 后 1 年时任何饮酒的累积发生率为 25%（95% CI，18%–34%），3 年时为 34%（95% CI，25%–44%）。 LT 后第 1 年持续饮酒的累积发生率为 10%（95% CI，6%–18%），第 3 年为 17%（95% CI，10%–27%）。在多变量分析中，只有较年轻的年龄与 LT 后饮酒有关 (P = .01)。 LT 后持续饮酒与死亡风险增加相关（风险比，4.59；P = .01）。在对 147 名因严重 AH 接受早期 LT（禁欲 6 个月前）的患者进行回顾性分析中，我们发现大多数患者存活 1 年（94%）和 3 年（84%），与因其他适应症接受肝移植的患者类似。 LT 后持续饮酒的情况很少见，但会导致死亡率增加。我们的研究结果支持选择性使用 LT 作为严重 AH 的治疗方法。需要进行前瞻性研究来优化选择标准、LT 后患者的管理以及长期结果。本文有一个附带的继续医学教育活动，也有资格获得 MOC 学分，第 e21 页。学习目标：完成此 CME 活动后，成功的学习者将能够确定患有严重酒精性肝炎的患者是否适合考虑早期肝移植，并确定移植后的预期结果
The American Consortium of Early Liver Transplantation for Alcoholic Hepatitis comprises 12 centers from 8 United Network for Organ Sharing regions studying early liver transplantation (LT) (without mandated period of sobriety) for patients with severe alcoholic hepatitis (AH). We analyzed the outcomes of these patients. We performed a retrospective study of consecutive patients with a diagnosis of severe AH and no prior diagnosis of liver disease or episodes of AH, who underwent LT before 6 months of abstinence from 2006 through 2017 at 12 centers. We collected data on baseline characteristics, psychosocial profiles, level of alcohol consumption before LT, disease course and treatment, and outcomes of LT. The interval of alcohol abstinence was defined as the time between last drink and the date of LT. The primary outcomes were survival and alcohol use after LT, defined as slip or sustained. Among 147 patients with AH who received liver transplants, the median duration of abstinence before LT was 55 days; 54% received corticosteroids for AH and the patients had a median Lille score of 0.82 and a median Sodium Model for End-Stage Liver Disease score of 39. Cumulative patient survival percentages after LT were 94% at 1 year (95% confidence interval [CI], 89%–97%) and 84% at 3 years (95% CI, 75%–90%). Following hospital discharge after LT, 72% were abstinent, 18% had slips, and 11% had sustained alcohol use. The cumulative incidence of any alcohol use was 25% at 1 year (95% CI, 18%–34%) and 34% at 3 years (95% CI, 25%–44%) after LT. The cumulative incidence of sustained alcohol use was 10% at 1 year (95% CI, 6%–18%) and 17% at 3 years (95% CI, 10%–27%) after LT. In multivariable analysis, only younger age was associated with alcohol following LT (P = .01). Sustained alcohol use after LT was associated with increased risk of death (hazard ratio, 4.59; P = .01). In a retrospective analysis of 147 patients who underwent early LT (before 6 months of abstinence) for severe AH, we found that most patients survive for 1 year (94%) and 3 years (84%), similar to patients receiving liver transplants for other indications. Sustained alcohol use after LT was infrequent but associated with increased mortality. Our findings support the selective use of LT as a treatment for severe AH. Prospective studies are needed to optimize selection criteria, management of patients after LT, and long-term outcomes. This article has an accompanying continuing medical education activity, also eligible for MOC credit, on page e21. Learning Objective: Upon completion of this CME activity, successful learners will be able to determine if a patient with severe alcoholic hepatitis is appropriate for consideration of early liver transplantation and identify expected outcomes after transplantation
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