Management of patients with cirrhosis awaiting liver transplantation
Management of patients with cirrhosis awaiting liver transplantation
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DOI：
10.1136/gut.2009.179937
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发表时间：
2011-03-01
期刊：
影响因子：
24.5
通讯作者：
Gines, Pere
中科院分区：
文献类型：
--
作者：
Cardenas, Andres;Gines, Pere
第一个人类原位肝移植（奥尔特）是在20世纪60年代初由托马斯Starzl在美国。1在此之前，几乎没有为晚期肝病患者提供失代偿的特征，如腹水，肝肾综合征（HRS），肝性脑病（HE），自发性细菌性腹膜炎（SBP），胃食管静脉曲张出血和/或肝细胞癌。这些患者预后不良，因为仅提供姑息性和对症治疗。奥尔特作为晚期肝病的公认疗法的出现完全改变了这种情况，为患者提供了治愈其患病肝脏的方法。在最初的几年里，在改进适应症和手术技术方面取得了重大进展。尽管如此，人们花了几年时间才意识到，最大限度地优化患者的移植前状态将转化为更好的移植后结果。2失代偿期肝硬化中最常见的需要积极治疗并改变移植前后结局的疾病包括低钠血症、SBP以及其他细菌感染、HE、HRS和肝细胞癌。在美国和欧洲，接受奥尔特的患者1年生存率分别接近85%和86%，3年生存率分别接近80%和79%。3 4然而，对器官的高需求和捐赠者的稳定供应导致许多移植中心等待名单中的发病率和死亡率增加。因此，对肝移植名单上的患者进行适当的护理，对于在适当的条件下达到奥尔特，确保奥尔特后的良好结果起着重要作用。在这方面，适当选择候选人在确定等候名单上的发病率和死亡率方面发挥着关键作用。选择进行奥尔特的患者接受全面评估，以排除可能妨碍手术的条件（主要是严重的共病条件，转移性癌症或无法生存或受益的患者不是候选人）。列出的患者的优先顺序是基于预测等待名单上的存活率的模型。虽然不同的国家使用不同的模型，但终末期肝病模型（MELD）评分是美国和欧洲一些国家使用的模型。该评分可准确预测不同病因肝病患者独立队列的短期死亡率。5然而，尽管器官分配政策和医疗服务有所改善，但病人仍需在等候名单上等待很长时间。这主要是由于对器官的需求量很大，而捐赠率很低;然而，这在不同国家之间有所不同。例如，在美国，名单上的平均等待时间是361天，而在英国是149天。6 7在列表上花费的时间的增加使患者处于发生上述许多并发症的风险中;因此，在此时间范围内的重要目标是优化患者的状况，防止进一步失代偿并治疗不仅影响移植前状态而且影响移植后结果的特定并发症。本文将重点介绍等待奥尔特患者的上述并发症。肝细胞癌，这是常见的代偿性和失代偿性肝硬化患者，也应该积极管理，然而，这个话题是超出了本审查的范围，并已讨论最近在其他地方。8腹水腹水是肝硬化最常见的并发症，如果患者不接受奥尔特，5年内死亡率为50%。9这是最常见的原因之一转诊评估奥尔特在.
INTRODUCTION The first human orthotopic liver transplantation (OLT) was performed in the early 1960s by Thomas Starzl in the USA. 1 Up until then there was little to offer patients with advanced liver disease with features of decompensation such ascites, hepatorenal syndrome (HRS), hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), gastro-oesophageal variceal bleeding, and/or hepatocellular carcinoma. These patients had a sinister prognosis because only palliative and symptomatic therapy was offered. The advent of OLT as an accepted therapy for advanced liver disease completely changed this scenario offering patients a cure to their diseased liver. In the initial years, significant advances were made in refining the indications and surgical technique. Nonetheless it took several years to realise that maximally optimising the pre-transplant status of patients would translate into better post-transplant outcomes. 2 The most common conditions in decompensated cirrhosis that require aggressive management and alter pre-and post-transplant outcome include hyponatraemia, SBP as well as other bacterial infections, HE, HRS, and hepatocellular carcinoma. In the USA and Europe, survival rates of patients who undergo OLT are near 85% and 86% at 1 year and 80% and 79% at 3years, respectively. 3 4 However, the high demand for organs and the steady availability of donors has led to increased morbidity and mortality in the waiting list in many transplant centres. Thus, proper care of patients on a liver transplantation list plays a fundamental role in reaching OLT in an adequate condition that ensures a good outcome after OLT. In this respect the appropriate selection of candidates plays a key role in determining waiting list morbidity and mortality. Patients who are selected for OLT undergo a thorough evaluation in order to exclude conditions that may preclude the operation (mainly serious comorbid conditions, metastatic cancer or those who will not survive or benefit are not candidates). The priority of listed patients is based on models that predict survival while on the waiting list. Although different models are used among different countries, the Model for End-stage Liver Disease (MELD) score is the model used in the USA and some countries in Europe. The score accurately predicts short-term mortality in independent cohorts of patients with different aetiologies of liver disease. 5 However, despite improvements in organ allocation policy and medical care, patients continue to spend a long time on the waiting list. This is mainly due to a high demand of organs and small donation rates; however, this varies among different countries. For instance, in the USA the average waiting time on the list is 361days whereas in the UK it is 149 days. 6 7 This increase of time spent on the list places patients at risk of developing many of the complications listed above; therefore, an important goal within this timeframe is to optimise the patient’s condition preventing further decompensation and treating specific complications that not only affect pre-transplant status but also posttransplant outcome. This article will focus on the above-mentioned complications in patients awaiting OLT. Hepatocellular carcinoma, which is commonly encountered in patients with compensated and decompensated cirrhosis, should also be managed aggressively, however, this topic is beyond the scope of this review, and has been discussed recently elsewhere. 8ASCITES Ascites is the most common complication of cirrhosis and is associated with 50% mortality at 5 years if patients do not receive OLT. 9 It is one of the most frequent reasons for referral for evaluation of OLT in …