Deceased-donor split-liver transplantation in adult recipients: is the learning curve over?
Deceased-donor split-liver transplantation in adult recipients: is the learning curve over?
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DOI：
10.1016/j.jamcollsurg.2013.06.005
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发表时间：
2013-10
影响因子：
5.2
通讯作者：
Kim HB
中科院分区：
文献类型：
--
作者：
Cauley RP;Vakili K;Fullington N;Potanos K;Graham DA;Finkelstein JA;Kim HB
在所有肝移植候选者中，婴儿的候补死亡率最高。死者供体劈离肝移植是一种提供成人和儿童移植物的技术，可能是降低这种不成比例的死亡率的最佳方法。然而，对成年分裂接受者风险增加的担忧阻碍了其广泛采用。我们的目的是确定成人受者劈裂肝移植后移植失败的当前风险。联合器官共享网络 (UNOS) 的数据来自 62,190 名首次接受已故捐献者肝脏移植的成年接受者 (1995-2010)（889 个分割移植物）。双变量危险因素（p<0.2）包含在移植类型对移植失败影响的 cox 比例风险模型中。与全肝受者相比，裂体肝受者的移植失败总体风险比 (HR) 为 1.26 (p<.001)。在前 MELD 时代（1995-2002），分裂肝 HR 为 1.45（p<.001），在 MELD 时代（2002-2010）为 1.10（p=.28）。相互作用分析表明，1 级受者和肝细胞癌 (HCC) 例外受者的劈裂移植物失败风险增加。排除高危受者，分割移植物和整体移植物具有相似的结果（HR .94，p=.59）。目前，在绝大多数情况下，劈裂肝和全肝受者之间的移植失败风险相似，这表明在不增加成年受者长期移植失败的总体风险的情况下，扩大劈肝分配是可能的。进一步的前瞻性分析应检查选择偏倚是否可能导致 HCC 或指定状态 1 受者的风险可能增加。
Infants have the highest waitlist mortality of all liver transplant candidates. Deceased-donor split liver transplantation, a technique that provides both an adult and pediatric graft, may be the best way to decrease this disproportionate mortality. Yet concern for an increased risk to adult split recipients has discouraged its widespread adoption. We aimed to determine the current risk of graft failure in adult recipients following split liver transplantation. United Network for Organ Sharing (UNOS) data from 62,190 first-time adult recipients of deceased-donor liver transplants (1995–2010) were analyzed (889 split grafts). Bivariate risk factors (p<0.2) were included in cox proportional hazards models of the effect of transplant type on graft failure. Split liver recipients had an over-all hazard-ratio (HR) of graft failure of 1.26 (p<.001) compared to whole liver recipients. The split liver HR was 1.45 (p<.001) in the pre-MELD era (1995–2002), and 1.10 (p=.28) in the MELD era (2002–2010). Interaction analyses suggested an increased risk of split graft failure in Status 1 recipients and those given an exception for hepatocellular carcinoma (HCC). Excluding higher-risk recipients, split and whole grafts had similar outcomes (HR .94, p=.59). The risk of graft failure is now similar between split and whole liver recipients in the vast majority of cases – demonstrating that the expansion of split liver allocation may be possible without increasing the overall risk of long-term graft failure in adult recipients. Further prospective analysis should examine if selection bias may account for the possible increase in risk for recipients with HCC or designated Status 1.