Decreased Urgency Among Liver Transplantation Candidates With Hepatocellular Carcinoma in the United States.
Decreased Urgency Among Liver Transplantation Candidates With Hepatocellular Carcinoma in the United States.
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美国患有肝细胞癌的肝移植候选人的紧迫性降低。
DOI：
10.1002/lt.26373
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发表时间：
2022
期刊：
影响因子：
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通讯作者：
Mehta,Neil
中科院分区：
文献类型：
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作者：
Kwong,AllisonJ;Ghaziani,TTara;Mehta,Neil
20 多年来，早期肝细胞癌 (HCC) 一直是肝移植 (LT) 的公认适应症。美国的分配政策不断完善，以保持公平性并优化 HCC 移植的效用，但所有符合 HCC 例外资格的患者仍获得相同的分数。该群体具有相当的异质性，等待名单退出的风险各不相同，具体取决于肿瘤特征，包括病变的数量和大小、甲胎蛋白 (AFP) 水平以及基线肝功能。此外，肝病人口统计数据的变化，包括非酒精性脂肪性肝炎 (NASH) 发病率的上升、丙型肝炎病毒的有效抗病毒治疗以及由于筛查计划和意识的改进而更早发现 HCC，可能会影响 LT 的总体生存获益。对 2005 年 1 月至 2021 年 6 月期间在器官采购和移植网络 (OPTN) 数据库中列出的所有接受初级 LT 的成年候选人进行了分析，这些候选人至少获得了 1 次批准的 HCC 例外。联合器官共享网络 (UNOS) T2 使用传统米兰标准定义，其中 1 个病变 2-5 cm 或 2-3 个病变每个≤ 3 cm，并且在第一个批准的例外情况下，孤立性 HCC 作为单个病变≤ 3 cm。复合低风险组被定义为终末期肝病模型（MELD）评分< 15，Child-Turcotte-Pugh（CTP）A级，AFP≤20 ng/mL，并且上市时单个肿瘤2-3 cm。（1）对于2016年1月11日之后的上市，使用MELD钠代替MELD，与分配政策的变化保持一致。 T2 HCC 患者使用最近提出的候补名单退出风险评分进行分类，该评分是使用 2010 年至 2014 年国家 OPTN 数据开发和验证的。(2) 按列入年份定义了四个时代：2005-2012 年、2013-2015 年、2016-2018 年和 2019-2021 年——选择与美国肝脏分配的重大政策变化相一致，包括更广泛的肝脏分配政策变化。 2013年的区域共享；2015年的“上限和延迟”，规定了6个月的等待时间；国家肝脏审查委员会根据该中心 2019 年移植时的 MELD 评分中位数进行评分。
Early-stage hepatocellular carcinoma (HCC) has been an accepted indication for liver transplantation (LT) now for over 20 years. Allocation policy in the United States has been continually refined to maintain equity and optimize the utility of transplantation for HCC, yet all patients qualifying for HCC exception still receive the same number of points. This group is quite heterogeneous, with varying risk of waitlist dropout dependent on tumor characteristics including number and size of lesions and alpha-fetoprotein (AFP) level, as well as baseline liver function. In addition, changing demographics of liver disease, including the rising incidence of nonalcoholic steatohepatitis (NASH), effective antiviral therapy for hepatitis C virus, and earlier detection of HCC due to improved screening programs and awareness, may influence the overall survival benefit to LT. All adult candidates listed for primary LT in the Organ Procurement and Transplantation Network (OPTN) database between January 2005 and June 2021 who received at least 1 approved HCC exception were analyzed. United Network for Organ Sharing (UNOS) T2 was defined using conventional Milan criteria, with 1 lesion 2-5 cm or 2-3 lesions each≤ 3 cm, and solitary HCC as a single lesion≤ 3 cm at the first approved exception. A composite low-risk group was defined as Model for End-Stage Liver Disease (MELD) score< 15, Child-Turcotte-Pugh (CTP) Class A, AFP≤ 20 ng/mL, and a single tumor 2-3 cm at listing.(1) For listings after January 11, 2016, MELD-sodium was used instead of MELD, aligning with the change in allocation policy. Patients with T2 HCC were categorized using a recently proposed waitlist dropout risk score developed and validated using national OPTN data from 2010 to 2014.(2) Four eras were defined by the year of listing: 2005-2012, 2013-2015, 2016-2018, and 2019-2021—chosen to coincide with major policy changes in liver allocation in the United States, including broader regional sharing in 2013;“cap and delay,” which instituted a 6-month waiting time, in 2015; and the National Liver Review Board with points based on the center’s median MELD score at transplantation in 2019.