Hepatocellular Carcinoma Is the Most Common Indication for Liver Transplantation and Placement on the Waitlist in the United States.
Hepatocellular Carcinoma Is the Most Common Indication for Liver Transplantation and Placement on the Waitlist in the United States.
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DOI：
10.1016/j.cgh.2016.11.034
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发表时间：
2017-05
期刊：
影响因子：
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通讯作者：
Leise MD
中科院分区：
文献类型：
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作者：
Yang JD;Larson JJ;Watt KD;Allen AM;Wiesner RH;Gores GJ;Roberts LR;Heimbach JA;Leise MD
丙型肝炎病毒感染和肝细胞癌患者的管理策略已经改变，基于终末期肝病模型(MELD)评分的肝脏分配策略也发生了变化。我们调查了美国不同时期肝移植病因学的发展趋势。我们进行了一项回顾性研究，使用器官共享联合网络/器官采购和移植网络注册数据来确定2004年1月1日至2015年12月31日期间在美国注册的所有成年肝移植患者。对于有多个诊断的受试者，肝细胞癌被认为是主要的诊断。为了确定从2011年开始的直接作用抗病毒药物的可用性是否影响了丙型肝炎病毒感染患者的移植前(死亡或辍学)和移植后结果，我们比较了2004-2010年和2011-2014年的数据。我们使用竞争风险分析来比较这些时期之间终端的差异。使用Kaplan-Maier分析评估移植前和移植后不同时期的结果差异，并使用对数等级检验进行比较。用对数等级检验检验了上市年份和肝移植前结果、肝移植年份和移植后存活时间之间的关系。采用比例风险回归方法评价具有潜在混杂因素的时间效应的可靠性。在109,018名登记者中，18.5%的人因肝细胞癌而登记接受肝移植。2015年，在注册者(23.9%的注册者)和接受者(27.2%的接受者)中，肝癌是主要的诊断。2004至2015年间，有丙型肝炎病毒感染的患者与无肝细胞癌患者的登记者比率增加了5.6倍，有乙肝病毒感染的患者增加了1.9倍，酗酒患者增加了2.7倍，非酒精性脂肪性肝炎患者增加了10.2倍。在调整协变量后，我们将2011-2014年期间与肝细胞癌注册者接受肝移植的概率降低联系在一起(风险比[HR]，0.62；P<；0.0001)。2011年至2014年期间，丙型肝炎(HR，0.9；P=.0003)、乙肝(HR，0.71；P=.002)或酒精(HR，0.9；P=.01)肝病患者因病情恶化或死亡而退学的概率降低，而丙型肝炎(HR，3.4；P<；0.0001)、乙肝病毒感染(HR，2.3；P=.004)或酗酒(HR，2.2；P<；0.0001)患者因临床改善而退榜的可能性增加。2011-2014年期间，移植物丢失或死亡的风险降低，在感染丙型肝炎病毒的受者中影响最大(HR，0.76；P<；.0001)。2015年，肝细胞癌是美国肝移植的主要适应症。尽管如此，肝移植的概率在肝细胞癌注册者中下降最多。移植前和移植后的结果都有所改善，特别是在感染了丙型肝炎病毒的患者中。
Management strategies for patients with hepatitis C virus (HCV) infection and hepatocellular carcinoma (HCC) have changed, along with liver allocation policies based on model for end-stage liver disease (MELD) score. We investigated etiologic-specific trends in liver transplantation in the United States (US) during different time periods. We performed a retrospective study, using the United Network for Organ Sharing/Organ Procurement and Transplantation Network registry data to identify all adult patients registered for liver transplantation in the US from January 1, 2004 through December 31, 2015. For subjects listed with multiple diagnoses, HCC was considered the primary listing diagnosis. To determine whether availability of direct-acting antiviral agents, which began in 2011, affected pre-transplant (death or dropout) and post-transplant outcomes for patients with HCV infection, we compared data from the time periods of 2004–2010 and 2011–2014. We used competing risk analysis to compare differences in endpoints between these periods. Differences between periods in pre- and post-transplantation outcomes were estimated using Kaplan-Maier analysis and compared using the log-rank test. Associations between year of listing and pre-liver transplant outcome, and year of liver transplant and survival following transplant, were examined using the log-rank test. Proportional hazard regression was used to evaluate the reliability of the time period effect with potential confounders. Among 109,018 registrants, 18.5% were registered for liver transplantation due to HCC. In 2015, HCC was the leading diagnosis among registrants (23.9% of registrations) and recipients (27.2% of recipients). Between 2004 and 2015, the ratio of registrants with vs without HCC increased 5.6-fold for patients with HCV infection, 1.9-fold for patients with HBV infection, 2.7-fold for patients with alcohol abuse, and 10.2-fold for patients with nonalcoholic steatohepatitis. After adjusting for covariates, we associated the period of 2011–2014 with a decreased probability that HCC registrants would undergo liver transplantation (hazard ratio [HR], 0.62; P<.0001). The period of 2011–2014 was also associated with decreased probability of dropout due to deterioration or death from HCV-induced (HR, 0.90; P=.0003), HBV-induced (HR, 0.71; P=.002), or alcohol-induced (HR, 0.90; P=.01) liver disease, and an increased probability of delisting due to clinical improvement in patients with HCV infection (HR, 3.4; P<.0001), HBV infection (HR, 2.3; P=.004, or alcohol abuse (HR, 2.2; P<0.0001). The period of 2011–2014 was associated with a decreased risk of graft loss or death, with the largest effect seen in HCV-infected recipients (HR, 0.76; P<.0001). HCC was the leading indication for liver transplantation in the US in 2015. Despite this, the probability of liver transplantation decreased the most in registrants with HCC. Pre- and post-transplantation outcomes have improved, particularly in patients with HCV infection.