目的:肾功能障碍是等待移植的失代偿期肝硬化患者预后的主要决定因素。我们假设,对于列表中相同的MELD分数,如果MELD评分的主要驱动因素是血清肌酐和血清胆红素或INR,那么肝移植前后的结局可能会有所不同.
方法:我们评估了2016年至2020年期间所有注册接受肝移植(LT)的成年患者,并排除了接受MELD例外或接受双器官移植的患者。使用K-Means聚类分析,我们把每个病人都分类为MELD-Br,MELD-INR或MELD-Cr取决于其MELD评分的主要变量。主要结果是意向治疗生存,定义为在有或没有LT的情况下上市后1年内的生存率。
结果:LT等候名单注册者的MELD得分分为3种亚型:MELD-Br(n=13,658),MELD-INR(n=13,809),和MELD-Cr(n=12,412)。ITT一年生存率为78%(MELD-Br),75%(MELD-INR),和65%(MELD-Cr),p<0.01。与男性相比,女性的每种MELD亚型的ITT生存率较低(例如,女性的MELDCr63%与男性的67%,p<0.0001)。MELD-Cr亚型在上市时具有最高的MELD(MELDCr23.4vsMELD-Br19.2vsMELDINR21.0),并且在3个月内MELD的跌幅最大(23%vs.12%vs21%)。在包括MELDNa在内的调整后分析中,与其他亚型相比,MELD-Cr与较高的WL死亡率(HR1.339,95%CI1.279-1.402)和较低的LT率(HR0.688,95%CI0.664-0.713)相关。
结论:对于等效的上市实践,具有MELD-Cr亚型的注册者具有较低的ITT存活率。MELD亚型可以作为一个更复杂的变量,用于动态评估死亡风险。为器官分配模型提供信息。
■MELD评分是候诊者死亡率的极好预测指标;然而,我们的工作强调,MELD评分的驱动因素很重要,尤其是肌酐升高导致的患者1年ITT死亡率较低.在Cr占优势的亚型中,女性的1年ITT死亡率也低于男性。这些结果对于医生和接受LT评估的患者很重要,因为肌酐可以作为预后的标志物,即使肌酐改善了预后仍然很差。有必要讨论移植的替代途径。我们的工作还强调了肾损伤的类型很重要,与肌酐显性亚型中的CKD患者相比,这些AKI更有可能死亡或留在候补名单上.
OBJECTIVE: Kidney dysfunction is a major determinant of prognosis in patients with decompensated cirrhosis awaiting transplantation. We hypothesized that for identical MELD scores at listing, outcomes before and after liver transplantation may vary if the predominant driver of the MELD score is serum creatinine versus serum bilirubin or INR.
METHODS: We evaluated all adult patients registered for liver transplantation (LT) between 2016 - 2020 and excluded patients receiving MELD exceptions or undergoing dual organ transplantation. Using K-Means clustering analysis, we classified each patient as MELD-Br, MELD-INR or MELD-Cr depending on the dominant variable for their MELD score. The primary outcome was intent-to-treat survival, defined as survival within 1 year from listing with or without LT.
RESULTS: MELD scores of LT waitlist registrants clustered into 3 subtypes: MELD-Br (n=13,658), MELD-INR (n=13,809), and MELD-Cr (n=12,412). One-year ITT survival was 78% (MELD-Br), 75% (MELD-INR), and 65% (MELD-Cr), p<0.01. ITT survival was lower for each MELD subtype for females compared to males (e.g. MELD Cr 63% females vs 67% males, p<0.0001). MELD-Cr subtype had the highest MELD at listing (MELD Cr 23.4 vs MELD-Br 19.2 vs MELD INR 21.0) and the largest decline in MELD over 3 months (23% vs. 12% vs 21%). In adjusted analyses including MELD Na, MELD-Cr compared to the other subtypes was associated with higher WL mortality (HR 1.339, 95% CI 1.279-1.402) and lower LT rates (HR 0.688, 95% CI 0.664-0.713).
CONCLUSIONS: For equivalent listing practices, registrants with MELD-Cr subtype have lower ITT survival. MELD subtype may serve as a more sophisticated variable for dynamic assessment of risk of mortality, to inform models for organ allocation.
UNASSIGNED: The MELD score is an excellent predictor of waitlist mortality; however, our work highlights that the driver of a patient\'s score MELD score matters and particularly those driven by elevated creatinine have a lower 1-year ITT mortality. The 1-year ITT mortality is also lower for women compared to men within the Cr-dominant subtype. These results are important for physicians and patients undergoing LT evaluation as creatinine may serve as a marker of prognosis and even if the creatinine improves the prognosis remains poor, necessitating discussion about alternative pathways for transplant. Our work also highlights that the type of kidney injury matters, in that those AKI were more likely to die or remain on the waitlist compared to those with CKD within the creatinine dominant subtype.