Retransplantation for recurrent hepatitis C in the model for end‐stage liver disease era: How should we or shouldn't we?
Retransplantation for recurrent hepatitis C in the model for end‐stage liver disease era: How should we or shouldn't we?
复制标题
终末期肝病时代模型中复发性丙型肝炎的再移植：我们应该或不应该如何？
DOI：
10.1053/jlts.2003.50215
复制
发表时间：
2003
影响因子：
4.6
通讯作者：
R. Ghobrial
中科院分区：
文献类型：
--
作者：
R. Ghobrial
Much debate has centered around the validity of retransplantation for recurrent disease in general and retransplantation for recurrent hepatitis C virus (HCV) disease in particular. On the one hand, concerns are based on poor survival outcomes after retransplantation, scarcity of cadaveric organ resources for orthotopic liver transplant (OLT) patients, continued deaths of primary OLT candidates on the waiting list, and the predicted increased requirements of re-OLT in transplant recipients with recurrent HCV disease. On the other hand, the arguments for re-OLT in HCV recipients are the limited efficacy of antiviral therapy in which re-OLT becomes the only viable option for patients with allograft failure. Further, in selected patients, retransplantation may be accompanied by good shortterm survival outcomes when performed in the early stages of recurrence. 1 To date, most of the relevant data have been single center experiences. Thus, this important discussion has proceeded in the absence of standardized data analysis that allows accurate comparisons across different practices. By using the Model for End-Stage Liver Disease (MELD) scores as the basis for data analysis, the landmark study by Watt et al from the University of Nebraska has provided much-needed insight for objective evaluation of re-OLT in both HCV and non-HCV recipients. In contrast to the United Network for Organ Sharing (UNOS) classification, the adoption of the MELD scores for organ allocation has provided a unique opportunity for objective stratification of transplantation candidates based on the severity of illness. 2 Analysis by the University of Nebraska group of the MELD scores for 2129 patients undergoing re-OLT from 1996 to 2002 that excluded causes of early retransplantation showed very important findings. First, survival after re-OLT decreased with increasing preoperative MELD scores. Patients who underwent retransplantation at a MELD score 20 showed 1-year survival rates between 65% and 83%. The best survival outcomes of 81% to 83% were achieved when retransplantation was performed at a MELD 10. One-year survival rates were decreased to approximately 60% in all re-OLT for non-HCV patients with MELD 25 and in re-OLT forHCV recipients with a MELD score 20. Most concerning was the extremely poor survival, which approximated 50%, in re-OLT patients with a MELD 30. Second, the mean MELD scores for re-OLT in HCV and non-HCV patients were 21.7 and 21.5, respectively. Taken together, these data indicate that a large proportion of patients currently undergo re-OLT at MELD scores that are associated with high mortality. Therefore, at a given MELD score, re-OLT may show a significantly higher death rate than primary transplantation. To improve re-OLT–associated outcomes, retransplantation must be undertaken at a lower MELD score than that used for primary OLT recipients.
