终末期肝病模型对肝移植病人的预后分析

目的 探讨终末期肝病模型(MELD)对肝移植病人早期生存率的预测价值.方法 92例肝移植病人进行回顾性分析,通过受试者特征曲线(ROC),计算Youden指数判定ROC曲线的截断值,根据截断值,制作Kaplan-Meier生存曲线,利用生存曲线分析MELD评分对肝移植术后3个月预后判断的准确性.结果 随访3个月内累计死亡8人,3个月死亡组和生存组MELD积分分别为24.88士11.97,16.11±10.81(P<0.05).MELD积分系统对肝移植术后3个月预后判断的截断值为16,生存曲线分析表明MELD评分能有效地区分可能死亡和可能存活的病人,并且证实MELD评分系统能够有效预测肝移植术后3个月生存、死亡可能性.结论 MELD评分系统可有效地预测肝移植病人的短期预后效果.     

乳酸浓度和终末期肝病模型评分对肝移植术后早期死亡率预测准确性的比较

目的比较乳酸浓度与终末期肝病模型(model for end-stage liver disease, MELD)预测肝移植术后早期死亡率的准确性,为临床提供一种简便及时的预测工具。方法回顾性分析2017年于本院接受同种异体肝移植手术的121例患者的临床资料,男92例,女29例,年龄25～78岁,ASAⅢ或Ⅳ级。按术后30 d内是否存活分为两组:生存组和死亡组。收集术前和术毕乳酸浓度,计算术前和术毕MELD评分。比较两组术前乳酸浓度、术毕乳酸浓度、术前MELD评分和术毕MELD评分。采用受试者工作特征(receiver operating characteristic, ROC)曲线比较术前和术毕乳酸浓度和MELD评分对肝移植患者术后早期(术后30 d)死亡率的预测准确性。结果术后30 d内存活109例(90.0%),死亡12例(10.0%)。死亡组术前MELD评分、术前乳酸浓度、术毕MELD评分和术毕乳酸浓度均明显高于生存组(P0.05)。术前乳酸浓度的ROC曲线下面积(area under the curve, AUC)为0.78(95%CI 0.63～0.93),临界值为2.43 mmol/L;术前MELD评分的AUC为0.70(95%CI 0.53～0.87),临界值为24.50分,两者AUC差异无统计学意义。术毕乳酸浓度的AUC为0.85(95%CI 0.70～0.99),临界值为9.57 mmol/L;术毕MELD评分的AUC为0.74(95%CI 0.61～0.88),临界值为25.42分;术毕乳酸浓度的AUC明显高于术毕MELD评分(P0.05)。结论乳酸浓度,尤其是术毕乳酸浓度对于肝移植术后早期死亡率的预测能力优于MELD评分。     

终末期肝病模型评分较高的良性终末期肝病患者肝移植疗效评价

目的 探讨终末期肝病模型(MELD)评分较高的良性终末期肝病患者的肝移植疗效.方法 回顾分析80例良性终末期肝病肝移植患者的资料,根据MELD评分的不同将患者分成两组,MELD评分≥30分的23例为高MELD评分组,MELD评分＜30分的57例为低MELD评分组.分别比较两组患者手术时间、术中无肝期、术中血液制品输入量、术后重症监护病房(ICU)治疗时间和受者1年存活率,同时比较死亡患者和存活患者的临床资料,寻找导致术后死亡的危险因素.结果 高MELD评分组的手术时间、术中血液制品输入量、ICU治疗时间以及术后3个月内的死亡率明显高于低MELD评分组,差异有统计学意义(P＜0.05),而术中无肝期和患者1年存活率,两组间的差异无统计学意义(P＞0.05).死亡者和存活者相比较,MELD评分的差异无统计学意义(P＞0.05),而术前机械通气、血清钠水平、持续性肝性脑病(重型)等方面的差异有统计学意义(P＜0.05).结论 对于良性终末期肝病患者,单纯依靠MELD评分不足以准确判断患者肝移植术后的生存状态,高MELD评分者也可获得较好的肝移植结果,术前严重的低钠血症、重度肝性脑病以及机械通气是除MELD评分以外影响患者术后生存状况的危险因素.     

活体肝移植治疗终末期肝病的研究进展

肝移植是治疗终末期肝病的有效治疗手段,为解决供体严重短缺的问题,在活体肝移植方面发展了新的手术技术,边缘供体已被用于活体肝移植以扩大供体库.     

儿童终末期肝病模型评分用于预测婴幼儿活体肝移植预后的作用

目的探讨儿童终末期肝病模型(PELD)评分系统用于预测婴幼儿活体肝移植预后的作用。方法回顾性分析2006年10月至2012年12月上海交通大学医学院附属仁济医院肝脏外科收治的101例小儿活体肝移植临床资料。患儿术前诊断均为胆道闭锁。术前对每例患儿进行PELD评分,根据PELD评分将患儿分为两组:低分组(PELD评分16分,62例)和高分组(PELD评分≥16分,39例)。比较两组患儿围手术期的基本情况及术后并发症发生率。结果两组患儿的手术年龄和体重差异均有统计学意义(均为P0.05),但两组性别、移植物(肝)重量/受体的体重、供肝冷缺血时间、术中失血量等差异均无统计学意义(均为P0.05)。PELD高分组患儿移植术后的肺部感染和胆道并发症发生率均明显高于低分组(均为P0.05)。结论术前PELD评分可用于预测婴幼儿肝移植的预后,为婴幼儿肝移植的围手术期的治疗、监护及护理措施的制定提供参考。对于术前PELD评分较高的患儿,应加强围手术期并发症的监护处理。     

活体肝移植治疗终末期肝病的研究进展

肝移植是治疗终末期肝病的有效治疗手段,为解决供体严重短缺的问题,在活体肝移植方面发展了新的手术技术,边缘供体已被用于活体肝移植以扩大供体库.     

活体肝移植治疗终末期肝病

目的 探讨活体肝移植(1iving donor liver transplantation,LDLT)供、受者术前评估和手术方式的选择.方法 回顾性分析1995年1月至2007年10月我中心95例LDLT患者的临床资料.良性终末期肝病92例,其中Wilson病45例;肝脏恶性肿瘤3例.结果 供肝切取不带肝中静脉右半肝31例,带肝中静脉右半肝3例,带肝中静脉左半肝51例,不带肝中静脉左半肝或左外叶10例.所有供者术后顺利恢复,均未出现严重并发症.受者随访1～86个月,良性终末期肝病受者1、3、5年累积生存率分别为89%(82例)、78%(71例)和73%(67例),其中Wilson病受者1、3、5年累积生存率分别为92%(42例)、89%(40例)和76%(34例).3例肝脏恶性肿瘤患者死亡2例,1例长期生存.供、受者铜代谢均恢复正常.结论 建立供者安全保障体系是LDLT开展的先决条件,选择合理的手术方式是提高受者生存率的关键.亲体肝移植是治疗Wilson病的有效手段.     

肝移植术改善良性终末期肝病病人生存质量的初步研究

目的 研究肝移植手术对良性终末期肝病病人生存质量的改变情况。方法 采用WHOQOL-BREF表对29例良性终末期肝病病人在肝移植术前、术后1～3个月、术后4～6个月以及术后6个月以上4个时间段进行生存质量的测评。结果 良性终末期肝病病人在生理领域、自身生存质量总的主观感受及对自身健康状况总的主观感受方面，肝移植术后的评分与术前相比差异有统计学意义（P〈0．05）。结论 肝移植术可以提高良性终末期肝病受者的生存质量。     

良性终末期肝病行肝移植的手术时机选择

目的 为了进一步总结和探讨良性终末期肝病行肝移植手术时机的合理选择和提高肝移植成功率。方法 回顾性分析了20例良性终末期肝病行肝移植手术的病人对手术时机的掌握以及术后出现的各种并发症。结果 本组病人UNOS分级：I级4例，2例出现颅内出血，1例出现严重的肺部感染致多器官功能衰竭；Ⅱ级15例，1例出现颅内出血，1例出现急性肾衰，1例出现门静脉血栓形成，1例术后表现为肝上下腔狭窄，4例出现肺部感染；Ⅲ级1例，术后恢复良好。结论 良性终末期肝病病人应合理选择肝移植手术时机，才能提高肝移植成功率。     

High model for end-stage liver disease score as a predictor of survival during long-term follow-up after liver transplantation

Background

The allocation of cadaveric livers for transplantation in the United States is now based on the severity of illness as determined by the Model for End-Stage Liver Disease (MELD), which was developed to predict short-term mortality in patients with cirrhosis. However, its impact to predict posttransplantation survival is controversial. The objective of this study was to determine the association of various pretransplantation risk factors, including the MELD score and whether its use to allocate organs is likely to lead to overall poorer outcomes of liver transplantation.

Methods

The 1,032 consecutive adult liver transplantation patients at King's College Hospital between 2 January 1994 and 29 December 2001 were examined for 9 preoperative risk factors, including MELD score, using univariate and multivariate techniques. Based on their pretransplantation MELD scores, we categorized recipients as low (<15) medium (15-25), or high (>25). Kaplan-Meier patient survival analysis was used to identify differences in outcomes.

Results

The patients had a mean age of 47.2 years and mean posttransplantation follow-up of 5.3 years. Univariate analysis showed recipient diabetes mellitus, renal dysfunction, and pretransplantation MELD score to be associated with patient survival. Multivariate analysis showed the MELD score to be significantly associated with death during long-term follow-up.

Conclusions

A high pretransplantation MELD score was associated with poor posttransplantation outcomes.     

Impact of the model for end-stage liver disease score on mortality after liver transplantation

Objective

The objective of this study was to analyze survival, and mortality, rates as well as its causes during the month following liver transplantation with respect to the model for end-stage liver disease (MELD) model.

Material and Methods

We reviewed the mortality at 24 and 48 hours as well as 1 and 4 weeks of 380 transplanted patients over the past 7 years with regard to the MELD score.

Results

The mean patient age was 55 years. Among subjects with MELD score ≤ 15 (n = 142; 37.36%), there were 34 deaths (23.94%), including 7 (4.92%) who died during the first month. The mean cause of death during this period was hemorrhage (n = 3; 8.8%). Among those with MELD scores between 16 and 18 (n = 76; 20%), the mortality rate increased to 23.68% (n = 18), including 3 who died during the first month (3.94%) with 1 case due to hemorrhage. Among the cohort with MELD scores between 19 and 21 (n = 78; 20.52%), 25 (32.05%) died, including 9 during the first month (11.53%). The most frequent cause of death was septic shock (n = 5; 20%). The mortality rate among patients with a MELD score between 22 and 24 was 22% (n = 11), of which 8% (n = 4) died in the month. The mean cause of death during this period was multiple organ dysfunction (n = 2; 18.1%). The patient group with a MELD score >24 had a 32.3% mortality rate (n = 11); 4 patients died during the first month following transplantation (11.76%). The most frequent cause of death was hemorrhage (n = 2; 18.1%).

Conclusions

Survival during the first month did not seem to be related to the MELD score at the time of transplantation, nor did we observe a direct correlation between the MELD score and the overall risk of mortality.     

肝移植综合技术的改进与体会

目的:总结本移植中心肝移植综合技术提高的经验.方法:回顾性分析我院两个阶段[1999～2004年和2005～2007年(后期)]因良性终末期肝病行肝移植术病人的生存率.结果:后期的肝移植病人术后1个月、3个月和1年生存率分别为91.9%、85.5%和80.0%,明显高于前期的71.8%、66.7%和64.1%.术后围手术期死亡的病人较多,而术后中远期的生存率变化不大,本中心最长的生存病例已达102个月.结论:肝移植术式的改良、移植肝预先用血浆进行灌注、术后肠内营养的应用及免疫抑制剂的减量或个体化应用是提高肝移植术后生存率的原因.     

Change in model for end-stage liver disease score on the transplant waiting list predicts survival in patients undergoing liver transplantation

Allocation of donor livers through the model for end-stage liver disease (MELD) score has resulted in a fall in waiting list deaths in the United States. Change in MELD score (DeltaMELD) whilst awaiting transplant has been suggested as a method of refining organ allocation. Our aims were to analyse the effect of DeltaMELD between listing and transplant, and examine its impact on patient survival, intensive care stay and hospital stay in 402 patients transplanted for chronic liver disease at a single centre. Patients who had a DeltaMELD score of >+1 point were more likely to die in hospital following transplant (P < 0.05) and had a significantly worse 12- and 36-month survival post transplant (P < 0.0001) when compared with patients with DeltaMELD 相似文献   

Impact of MELD-based allocation on end-stage renal disease after liver transplantation

The proportion of patients undergoing liver transplantation (LT), with concomitant renal dysfunction, markedly increased after allocation by the model for end-stage liver disease (MELD) score was introduced. We examined the incidence of subsequent post-LT end-stage renal disease (ESRD) before and after the policy was implemented. Data on all adult deceased donor LT recipients between April 27, 1995 and December 31, 2008 (n = 59 242), from the Scientific Registry of Transplant Recipients, were linked with Centers for Medicare & Medicaid Services' ESRD data. Cox regression was used to (i) compare pre-MELD and MELD eras with respect to post-LT ESRD incidence, (ii) determine the risk factors for post-LT ESRD and (iii) quantify the association between ESRD incidence and mortality. Crude rates of post-LT ESRD were 12.8 and 14.5 per 1000 patient-years in the pre-MELD and MELD eras, respectively. Covariate-adjusted post-LT ESRD risk was higher in the MELD era (hazard ratio [HR]= 1.15; p = 0.0049). African American race, hepatitis C, pre-LT diabetes, higher creatinine, lower albumin, lower bilirubin and sodium >141 mmol/L at LT were also significant predictors of post-LT ESRD. Post-LT ESRD was associated with higher post-LT mortality (HR = 3.32; p < 0.0001). The risk of post-LT ESRD, a strong predictor of post-LT mortality, is 15% higher in the MELD era. This study identified potentially modifiable risk factors of post-LT ESRD. Early intervention and modification of these risk factors may reduce the burden of post-LT ESRD.     

成人良性终末期肝病肝移植术后中远期死亡的危险因素分析

目的 了解成人良性终末期肝病肝移植患者术后中远期的生存情况和导致中远期生存率下降的危险因素.方法 回顾性分析2003年10月至2007年6月行原位肝移植手术且术后存活时间超过1年的221例良性终末期肝病受者的资料,选取包括受者术前变量、供者变量、术中变量和受者术后变量共26个可能影响患者长期存活的危险因素,采用Cox回归分析筛选出影响肝移植受者术后长期存活的独立危险因素.结果 221例受者的随访率为97.3%(215/221),平均随访时间为(36.4±6.9)个月(12～56个月).其中28例在术后1年后死亡,主要死亡原因依次为感染(5.0%,11/221)、胆道并发症(3.6%,8/221)、乙型肝炎复发或再感染(1.4%,3/221).保留在Cox回归方程内的协变量为高龄(RR=2.325,P=0.009)、ABO血型(RR=2.206,P=0.015)、冷缺血时间(RR=3.001,P=0.000)、术后感染部位(RR=1.665,P=0.007)和胆道并发症(RR=2.655,P=0.004).结论 影响受者术后中远期存活的危险因素包括年龄≥60岁、ABO血型不符、冷缺血时间>12 h、术后肺部感染和移植肝胆管弥漫性狭窄.     

Predicting outcome after liver transplantation: utility of the model for end-stage liver disease and a newly derived discrimination function

BACKGROUND: The Model for End-Stage Liver Disease (MELD) has been found to accurately predict pretransplant mortality and is a valuable system for ranking patients in greatest need of liver transplantation. It is unknown whether a higher MELD score also predicts decreased posttransplant survival. METHODS: We examined a cohort of patients from the United Network for Organ Sharing (UNOS) database for whom the critical pretransplant recipient values needed to calculate the MELD score were available (international normalized ratio of prothrombin time, total bilirubin, and creatinine). In these 2,565 patients, we analyzed whether the MELD score predicted graft and patient survival and length of posttransplant hospitalization. RESULTS: In contrast with its ability to predict survival in patients with chronic liver disease awaiting liver transplant, the MELD score was found to be poor at predicting posttransplant outcome except for patients with the highest 20% of MELD scores. We developed a model with four variables not included in MELD that had greater ability to predict 3-month posttransplant patient survival, with a c-statistic of 0.65, compared with 0.54 for the pretransplant MELD score. These pretransplant variables were recipient age, mechanical ventilation, dialysis, and retransplantation. Recipients with any two of the three latter variables showed a markedly diminished posttransplant survival rate. CONCLUSIONS: The MELD score is a relatively poor predictor of posttransplant outcome. In contrast, a model based on four pretransplant variables (recipient age, mechanical ventilation, dialysis, and retransplantation) had a better ability to predict outcome. Our results support the use of MELD for liver allocation and indicate that statistical modeling, such as reported in this article, can be used to identify futile cases in which expected outcome is too poor to justify transplantation.