Determinants of outcome among patients with acute liver failure listed for liver transplantation in the United States.
Determinants of outcome among patients with acute liver failure listed for liver transplantation in the United States.
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DOI：
10.1002/lt.24347
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发表时间：
2016-04
期刊：
影响因子：
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通讯作者：
Acute Liver Failure Study Group
中科院分区：
文献类型：
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作者：
Reddy KR;Ellerbe C;Schilsky M;Stravitz RT;Fontana RJ;Durkalski V;Lee WM;Acute Liver Failure Study Group
急性肝衰竭（ALF）后的结果分析通常包括所有ALF患者，无论他们是否列入肝移植（LT）。我们假设，对入选患者的限制性分析可能会对与结果相关的因素提供新的见解，将注意力集中在入选后的疾病演变上。对2000年至2013年间纳入美国急性肝衰竭研究组登记的成年ALF患者进行分析，以确定与纳入后21天结局相关的基线因素。我们根据研究入院后3周的结果对617例患者（占整个ALF组的36%）进行了分类：117例患者自发存活（无LT， SS）， 108例无LT死亡，392例接受了LT。只有22%的对乙酰氨基酚（APAP） ALF患者被列入名单；然而，这组173名患者表现出更严重的疾病：更高的昏迷等级，更多的患者需要呼吸机、血管加压剂或肾脏替代治疗支持。只有62/173（36%）的APAP患者接受了移植，而药物性肝损伤患者为66%，自身免疫性肝损伤患者为86%，乙型肝炎相关ALF患者为71%。APAP患者比非APAP患者更容易死亡（24%对17%），中位死亡时间更早（2天对4.5天）。尽管病情更严重，APAP组仍有40%的SS率，而非APAP组的SS率为11% （p < 0.001）。APAP结果发展迅速，主要是SS或死亡。在所有病因中，APAP ALF列为LT的患者死亡率最高，而更缓慢发展的病因导致更高的LT发生率，因此死亡人数更少。所有ALF患者，特别是APAP型ALF患者，必须在早期决定是否移植。
Analyses of outcomes after acute liver failure (ALF) have typically included all ALF patients regardless of whether they were listed for liver transplantation (LT). We hypothesized that limiting analysis to listed patients might provide novel insights into factors associated with outcome, focusing attention on disease evolution after listing. Listed adult ALF patients enrolled in the US Acute Liver Failure Study Group registry between 2000 and 2013 were analyzed to determine baseline factors associated with 21-day outcomes after listing. We classified 617 patients (36% of overall ALF group) by 3-week outcome after study admission: 117 survived spontaneously (without LT, SS), 108 died without LT, and 392 underwent LT. Only 22% of acetaminophen (APAP) ALF patients were listed; however, this group of 173 patients demonstrated greater illness severity: higher coma grades, and more patients required ventilator, vasopressor or renal replacement therapy support. Only 62/173 (36%) of APAP patients received a graft, versus 66% for drug-induced liver injury patients, 86% for autoimmune and 71% for hepatitis B-related ALF. APAP patients were more likely to die than non-APAP patients (24% vs 17%), and the median time to death was sooner (2 vs 4.5 days). Despite greater severity of illness, the listed APAP group still had a SS rate of 40% vs. 11% for non-APAP causes (p < 0.001). APAP outcomes evolve rapidly, mainly to SS or death. Patients with APAP ALF listed for LT had the highest death rate of any etiology, while more slowly evolving etiologies yielded higher LT rates, and consequently, fewer deaths. Decisions to list and transplant must be made early in all ALF patients, particularly in those with APAP ALF.