- 作者：Aless ; ro Vitale ; Michael L. Volk ; Tullia Maria De Feo ; Patrizia Burra ; Anna Chiara Frigo ; Rafael Ramirez Morales ; Luciano De Carlis ; Luca Belli ; Michele Colledan ; Stefano Fagiuoli ; Giorgio Rossi ; Enzo Andorno ; Umberto Baccarani ; Enrico Regalia ; Marco Vivarelli ; Matteo Donataccio ; Umberto Cillo ; Liver Transplantation North Italy Transplant program (NITp) working group
- 关键词：LT ; Liver Transplantation ; HCC ; hepatocellular carcinoma ; WL ; waiting list ; MELD ; model for end-stage liver disease ; AFP ; alpha-fetoprotein ; INR ; international normalized ratio ; NITp ; North Italy Transplant program ; IQR ; interquartile range ; CR ; competing risk ; HCV ; hepatitis C virus ; HBV ; hepatitis B virus ; HR ; hazard ratio ; CI ; confidence interval
- 刊名：Journal of Hepatology
- 出版年：February, 2014
- 年：2014
- 卷：60
- 期：2
- 页码：290-297
- 全文大小：973 K
Background & Aims
The current organ allocation system for liver transplantation (LT) creates an imbalance between patients with and without hepatocellular carcinoma (HCC). We describe a model designed to re-establish allocation equity among patient groups using transplant benefit as the common endpoint.Methods
We enrolled consecutive adult patients entering the waiting list (WL group, n = 2697) and undergoing LT (LT group, n = 1702) during the period 2004-2009 in the North Italy Transplant program area. Independent multivariable regressions (WL and LT models) were created for patients without HCC and for those with stage T2 HCC. Monte Carlo simulation was used to create distributions of transplant benefit, and covariates such as Model for End-stage Liver Disease (MELD) and alpha-fetoprotein (AFP) were combined in regression equations. These equations were then calibrated to create an 鈥淢ELD equivalent鈥?which matches HCC patients to non-HCC patients having the same numerical MELD score.
Results
Median 5 year transplant benefit was 15.12 months (8.75-25.35) for the non-HCC patients, and 28.18 months (15.11-36.38) for the T2-HCC patients (p <0.001). Independent predictors of transplant benefit were MELD score (estimate = 0.89, p <0.001) among non-HCC patients, and MELD (estimate = 1.14, p <0.001) and logAFP (estimate = 鈭?.46, p <0.001) among HCC patients. The equation 鈥淗CC-MELD鈥?#xA0;= 1.27 鈭?#xA0;MELD - 0.51 鈭?#xA0;logAFP + 4.59 calculates a numerical score for HCC patients, whereby their transplant benefit is equal to that of non-HCC patients with the same numerical value for MELD.
Conclusions
We describe a method for calibrating HCC and non-HCC patients according to survival benefit, and propose that this method has the potential, if externally validated, to restore equity to the organ allocation system.