Early Liver Transplantation for Severe Alcohol-Associated Hepatitis and a History of Prior Liver Decompensation.
Early Liver Transplantation for Severe Alcohol-Associated Hepatitis and a History of Prior Liver Decompensation.
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DOI：
10.14309/ajg.0000000000001901
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发表时间：
2022-12-01
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在已发表的酒精相关性肝炎（AH）早期肝移植（LT）研究中，排除了既往肝功能失代偿的患者。这一标准的适当性尚不清楚。在美国酒精相关性肝炎早期肝移植联盟的6个站点中，我们纳入了2007年至2020年期间临床诊断AH的连续早期LT。患者被分层为首次与既往肝功能失代偿史，后者定义为腹水、肝性脑病、静脉曲张出血或黄疸的诊断，以及该事件后饮酒的证据。校正的考克斯回归评估了首次（与先前）失代偿与LT后死亡率和有害（即，任何酗酒和/或频繁）饮酒。共纳入241例LT接受者（210例首次接受者vs 31例既往失代偿者）：中位年龄43岁vs 38岁（P = 0.23），终末期肝病模型钠评分为39 vs 39（P = 0.98），LT后随访2.3 vs 1.7年（P = 0.08）。首次失代偿与既往失代偿的未校正1年和3年生存率分别为93%（95%置信区间[CI] 89%-96%）vs 86%（95% CI 66%-94%）和85%（95% CI 79%-90%）vs 78%（95% CI 57%-89%）。既往（与首次）失代偿与较高的校正后LT后死亡率（校正后风险比2.72，95% CI 1.61-4.59）和有害酒精使用（校正后风险比1.77，95% CI 1.07-2.94）相关。既往肝功能失代偿与肝移植后死亡率和有害酒精使用的风险较高相关。这些结果是一个初步的安全性信号，并验证了首次失代偿作为AH患者早期LT的考虑标准。然而，高3年生存率表明早期LT的生存获益，需要更大规模的研究来完善这一标准。这些结果表明，既往肝功能失代偿是一个危险因素，但不是早期LT的绝对禁忌症。
In the published studies of early liver transplantation (LT) for alcohol-associated hepatitis (AH), patients with a prior liver decompensation are excluded. The appropriateness of this criteria is unknown. Among 6 American Consortium of Early Liver Transplantation for Alcohol-Associated Hepatitis sites, we included consecutive early LT for clinically diagnosed AH between 2007 and 2020. Patients were stratified as first vs prior history of liver decompensation, with the latter defined as a diagnosis of ascites, hepatic encephalopathy, variceal bleeding, or jaundice, and evidence of alcohol use after this event. Adjusted Cox regression assessed the association of first (vs prior) decompensation with post-LT mortality and harmful (i.e., any binge and/or frequent) alcohol use. A total of 241 LT recipients (210 first vs 31 prior decompensation) were included: median age 43 vs 38 years (P = 0.23), Model for End-Stage Liver Disease Sodium score of 39 vs 39 (P = 0.98), and follow-up after LT 2.3 vs 1.7 years (P = 0.08). Unadjusted 1- and 3-year survival among first vs prior decompensation was 93% (95% confidence interval [CI] 89%–96%) vs 86% (95% CI 66%–94%) and 85% (95% CI 79%–90%) vs 78% (95% CI 57%–89%). Prior (vs first) decompensation was associated with higher adjusted post-LT mortality (adjusted hazard ratio 2.72, 95% CI 1.61–4.59) and harmful alcohol use (adjusted hazard ratio 1.77, 95% CI 1.07–2.94). Prior liver decompensation was associated with higher risk of post-LT mortality and harmful alcohol use. These results are a preliminary safety signal and validate first decompensation as a criterion for consideration in early LT for AH patients. However, the high 3-year survival suggests a survival benefit for early LT and the need for larger studies to refine this criterion. These results suggest that prior liver decompensation is a risk factor, but not an absolute contraindication to early LT.