为急性和慢性肝功能衰竭的重症患者进行肝移植：一项前瞻性的全国候补名单优先排序计划

IF 13.6 Q1 HEALTH CARE SCIENCES & SERVICES

Lancet Regional Health-Europe Pub Date : 2024-11-01 DOI:10.1016/j.lanepe.2024.101067

William Bernal , Rhiannon Taylor , Ian A. Rowe , Abhishek Chauhan , Matthew J. Armstrong , Michael E.D. Allison , Gwilym Webb , Tasneem Pirani , Joanna Moore , Laura Burke , Steven Masson , David Cressy , Brian J. Hogan , Rachel Westbrook , Rajiv Jalan , Kenneth J. Simpson , John Isaac , Douglas Thorburn

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引用次数: 0

摘要

背景急性慢性肝衰竭（ACLF）是慢性肝病（CLD）的并发症，它结合了快速进展的肝脏和肝外多器官衰竭，短期死亡率高。有效的治疗方案非常有限，而肝移植（LT）由于受体死亡率高和资源使用量大而很少使用。回顾性报告显示，近期的治疗效果可能有所改善，但尚未对ACLF的LT使用情况进行前瞻性评估。方法2021年5月，英国所有7家LT中心启动了一项前瞻性计划，通过在新的国家层级注册，为选定的ACLF受者优先分配肝脏移植物。候选者由中心多学科团队筛选，纳入标准为肝硬化CLD伴ACLF，需要重症监护（CC）器官支持，预计1个月死亡率为50%。排除标准包括年龄≥60岁、曾接受过LT治疗、合并症或药物滥用情况排除了选择性LT治疗。研究结果52名患者在ACLF层级登记，中位（IQR）年龄为46（39-52）岁，ACLF等级为3（3-3）级，终末期肝病模型（MELD）为39（35-40）级。登记时，32 人（62%）需要机械通气，44 人（85%）需要血管加压，46 人（89%）需要肾脏替代。42人（81%）在登记后2（2-5）天接受了LT治疗：10人（19%）没有接受移植。所有非移植患者均在登记后中位 7 (4-13) 天死亡（与 LT 相比，P < 0.0001）。LT后随访212（119-530）天，患者存活率为81%（95% CI 66-91）：登记后28天、90天和1年的存活率分别为93%、86%和77%。LT受者的CC和住院时间中位数分别为16天（8-28天）和35天（23-54天）。在没有其他类似有效干预措施的情况下，对于选定的受者而言，LT是一种实用、高效的治疗选择。

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Liver transplantation for critically ill patients with acute on chronic liver failure: a prospective national programme of waitlist prioritisation

Background

Acute on Chronic Liver Failure (ACLF) complicates chronic liver disease (CLD) combining rapidly progressive hepatic with extra-hepatic multiple organ failure and high short-term mortality. Effective therapeutic options are very limited, and liver transplantation (LT) seldom utilised through concerns of high recipient mortality and resource use. Retrospective reports suggest recent outcomes may have improved, but use of LT for ACLF has not been prospectively assessed.

Methods

A prospective programme of prioritised liver graft allocation for selected recipients with ACLF through registration on a new national tier, initiated in May 2021 in all 7 United Kingdom LT centres. Candidates were selected by centre multidisciplinary teams, with inclusion criteria mandating cirrhotic CLD with ACLF requiring critical care (CC) organ support and expected 1-month mortality >50%. Exclusion criteria included age ≥60 years, previous LT, comorbidity or substance misuse profile precluding elective LT. A pilot 50 registrations were planned, with pre-specified futility criteria of a 1-year post-LT survival of 60%.

Findings

Fifty-two patients were registered on the ACLF tier, median (IQR) age 46 (39–52) years, ACLF grade 3 (3–3) and Model for End-stage Liver Disease (MELD) 39 (35–40). At registration 32 (62%) required mechanical ventilation, 44 (85%) vasopressors and 46 (89%) renal replacement. Forty-two (81%) underwent LT 2 (2–5) days after registration: 10 (19%) did not. All non-transplanted died at median 7 (4–13) days after registration (p < 0.0001 vs. LT). Post-LT follow-up was 212 (119–530) days and patient survival 81% (95% CI 66–91): 28-, 90-day and 1-year survival after registration 93%, 86% and 77%. Median length of CC and hospital stay in LT recipients was 16 (8–28) and 35 (23–54) days respectively.

Interpretation

We report the first prospective national series of prioritised liver transplantation for critically ill patients with ACLF. For selected recipients LT is a practical and highly effective treatment option where no other similarly effective interventions exist.

Funding

There was no funding for the study.

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来源期刊

Lancet Regional Health-Europe Multiple-

CiteScore

19.90

自引率

1.40%

发文量

260

审稿时长

9 weeks

期刊介绍： The Lancet Regional Health – Europe, a gold open access journal, is part of The Lancet's global effort to promote healthcare quality and accessibility worldwide. It focuses on advancing clinical practice and health policy in the European region to enhance health outcomes. The journal publishes high-quality original research advocating changes in clinical practice and health policy. It also includes reviews, commentaries, and opinion pieces on regional health topics, such as infection and disease prevention, healthy aging, and reducing health disparities.