Factors Associated with Survival of Patients With Severe Acute-On-Chronic Liver Failure Before and After Liver Transplantation
Factors Associated with Survival of Patients With Severe Acute-On-Chronic Liver Failure Before and After Liver Transplantation
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DOI：
10.1053/j.gastro.2018.12.007
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发表时间：
2019-04-01
期刊：
影响因子：
29.4
通讯作者：
Wong, Robert J.
中科院分区：
文献类型：
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作者：
Sundaram, Vinay;Jalan, Rajiv;Wong, Robert J.
背景与目的：慢性加急性肝衰竭（ACLF）伴3个或3个以上器官衰竭（ACLF-3）患者的肝移植存在争议。我们根据终末期肝病模型（MELD）评分与ACLF分类比较了肝脏等待名单死亡率或移除率。我们还研究了ACLF-3患者肝移植后1年生存率降低的相关因素。方法：我们分析了2005年至2016年联合器官共享网络（UNOS）的数据。我们确定了等待名单上的患者（100，594）和接受肝脏移植的患者（50，552）。ACLF患者根据欧洲肝脏慢性肝衰竭标准研究协会确定。采用竞争风险回归、Kaplan-Meier分析和考克斯比例风险回归评价结局。研究结果：与其他ACLF组相比，ACLF-3患者更有可能死亡或从等待名单中删除，无论MELD-钠（MELD-Na）评分如何; ACLF-3评分和MELD-Na评分低于25的患者比例最大（28天时为43.8%）。肝移植术中的机械通气（风险比[HR] 1.49; 95%置信区间[CI] 1.22-1.84），供体风险指数高于1.7（HR 1.22; 95% CI 1.09-1.35），并在上市后30天内进行肝移植（HR 0.89; 95%CI 0.81-0.98）与肝移植后1年生存率独立相关。在对UNOS登记处数据的分析中，我们发现肝移植等待名单上的ACLF-3患者死亡率很高，即使是那些MELD-Na分数较低的人。因此，无论MELD-Na评分如何，某些ACLF-3患者的结局都很差。肝移植增加了这些患者的生存几率，特别是如果在等待名单上放置的30天内进行。肝移植时的机械通气和边缘器官的使用与死亡风险增加相关。
BACKGROUND & AIMS: Liver transplantation for patients with acute-on-chronic liver failure (ACLF) with 3 or more failing organs (ACLF-3) is controversial. We compared liver waitlist mortality or removal according to model for end-stage liver disease (MELD) score vs ACLF category. We also studied factors associated with reduced odds of survival for 1 year after liver transplantation in patients with ACLF-3. METHODS: We analyzed data from the United Network for Organ Sharing (UNOS) from 2005 through 2016. We identified patients who were on the waitlist (100,594) and those who received liver transplants (50,552). Patients with ACLF were identified based on the European Association for the Study of the Liver-chronic liver failure criteria. Outcomes were evaluated with competing risks regression, Kaplan-Meier analysis, and Cox proportional hazards regression. RESULTS: Patients with ACLF-3 were more likely to die or be removed from the waitlist, regardless of MELD-sodium (MELD-Na) score, compared with the other ACLF groups; the proportion was greatest for patients with an ACLF-3 score and MELD-Na score below 25 (43.8% at 28 days). Mechanical ventilation at liver transplantation (hazard ratio [HR] 1.49; 95% confidence interval [CI] 1.22-1.84), donor risk index above 1.7 (HR 1.22; 95% CI 1.09-1.35), and liver transplantation within 30 days of listing (HR 0.89; 95% CI 0.81-0.98) were independently associated with survival for 1 year after liver transplantation CONCLUSIONS: In an analysis of data from the UNOS registry, we found high mortality among patients with ACLF-3 on the liver transplant waitlist, even among those with lower MELD-Na scores. So, certain patients with ACLF-3 have poor outcomes regardless of MELD-Na score. Liver transplantation increases odds of survival for these patients, particularly if performed within 30 days of placement on the waitlist. Mechanical ventilation at liver transplantation and use of marginal organs were associated with increased risk of death.