11月《胃肠病学》发表的一项报告显示，在接受肝移植之前死亡或退出等待名单的等待肝移植患者中，84%的患者至少曾拒绝1次供体肝脏。更令人惊讶的是，大多数患者在等待期间拒绝移植不止1次，中位拒绝次数高达6次，而“被拒绝的”供体器官后来均被成功用于优先级别较低的患者。加州大学旧金山分校的Jennifer Cindy Lai博士及其同事在报告中指出，上述结果表明，等待名单中患者的死亡率“并非仅仅是由于缺少移植机会，而常常是其拒绝移植机会的结果”。研究者分析了美国器官共享/器官获取移植联合网络数据库中2005~2010年列入等待名单的33,389例年龄≥18岁的等待肝移植患者的器官提供情况。如此多的适宜肝脏供体被拒绝的最初原因尚不清楚，患者病历中通常记录了一些不明确的原因，可分为6大类：供体年龄或器官质量不适；供体器官大小/重量不适；供体ABO血型不相容、“社会史”、“阳性血清学试验”或“器官解剖学损伤或缺陷”等其他不适因素；受体未做好准备，因为患者生病、不近便而拒绝器官或同时需要多器官移植；移植手术本身问题，如因医院“工作量繁重”或外科医生或手术室不足，未能及时答复器官提供者；器官运送距离过远。共计20%的受试者(6,737例)在接受移植手术前死亡或因为病情太重而退出等待名单，其中5,680例(84%)患者在死亡前或退出等待名单前曾有≥1次获得供体肝脏的机会。供体肝脏被拒绝的原因大多(68%)是“供体年龄或器官质量不适”，器官大小不适、“其他供体因素”、受体没做好准备、移植手术或其他因素分别占9%、15%、4%和4%。研究者认为，作为主要拒绝原因的“供体质量或年龄不适”几乎肯定“并未准确或全面反映拒绝的真正原因。”虽然符合标准条件的高质量肝脏也因所谓“供体年龄或器官质量不适”而遭拒绝，但研究者发现，这些被拒绝的高质量肝脏与其他第1次即被接受的高质量肝脏的移植失败风险并无差异。导致如此高的拒绝率必定还有其他原因，但需要更加个体化的资料才能确定这些细微原因。研究者建议，为降低明显可用的器官的被拒率，移植界应“淡化非理想供体肝脏的污名，为等待患者设立切合实际的预期”，从而使他们不要因期待更好的器官而错过合适的供体肝脏。患者也应认识到在等待期间死亡或肝病突然恶化的不可预测性，应意识到与继续等待相比，接受移植可带来生存方面的受益。最后，还应鼓励等待患者尽快完成移植手术准备检查，以免仅仅因为没有进行必要的心脏检查或癌症筛查而不得不拒绝供体器官。该研究由美国国立糖尿病消化病肾病研究所和加州大学旧金山分校资助。研究者无相关利益冲突报告。
By: MARY ANN MOON, Internal Medicine News Digital Network
Eighty-four percent of candidates on the wait-list for liver transplant who either died or were removed from the list before they were able to undergo transplantation declined at least one offer of a donor liver, Dr. Jennifer Cindy Lai of the University of California, San Francisco, and her colleagues reported in the November issue of Gastroenterology.
Even more surprising, most of these candidates declined "not just one or two but a median of six liver offers during their time on the wait-list."
The "declined" donor organs were then successfully transplanted into lower-priority recipients.
These findings suggest that mortality among wait-listed patients "is not simply a result of not having the opportunity for transplantation, as many of us assume. Rather, wait-list mortality appears to result from opportunities for transplantation that were declined," Dr. Lai and her associates wrote.
The reasons that so many viable donor livers were initially declined are not yet clear. General, somewhat vague reasons were listed but not fully explained in the records the researchers analyzed for this study, which they obtained from the United Network for Organ Sharing/Organ Procurement Transplantation Network database.
The investigators assessed organ offers to 33,389 liver transplant candidates aged 18 years and older who were wait-listed across the United States between 2005 and 2010.
The reasons that proffered organs were declined, as listed in the medical records, fit into six broad categories: unfavorable donor age or quality of organ; unfavorable donor organ size/weight; other unfavorable donor factors, such as ABO blood transfusion incompatibility, "social history," "positive serologic tests," or "organ anatomical damage or defect"; unreadiness of the recipient, usually because he or she was ill, unavailable, refused the organ, or required multiple organ transplants at the same time; problems with the transplant program itself, such as a "heavy workload" or unavailability of a surgeon or operating room at the recipient’s medical center, failure to respond to the offer in a timely way, or excessive distance to ship the organ.
A total of 20% of the study population (6,737 patients) died or were removed from the wait-list because they became too sick before they could undergo transplantation. A total of 5,680 (84%) of those patients had been offered one or more donor livers before they died or were taken off the list.
Offers of donor livers were declined most often (68%) because of "unfavorable donor age or quality of organ," whereas 9% were declined because of unfavorable organ size, 15% because of "other donor factors," 4% because the recipient wasn’t ready, and 4% because of transplant program or miscellaneous other factors.
However, the dominant use of the "donor quality or age" refusal code in the database almost certainly "does not accurately or fully capture the true refusal reason," Dr. Lai and her associates said.
Even livers judged to be of high quality according to standard criteria were declined because of supposed "unfavorable donor age or quality of organ." But the investigators found no difference in the risk of graft failure between such high-quality livers that were declined and other high-quality livers that were accepted on the first offer.
Other reasons must be playing an important role in this high rate refusal, but "the nuances of these refusals cannot be determined" without more individualized data, they said.
Dr. Lai and her colleagues suggested that to cut down on refusals of apparently viable organs, the transplant community should "reduce the stigma associated with non–ideal livers, and set realistic expectations for wait-listed candidates" so that they’re less likely to pass up a suitable donation while assuming that a better offer will come along.
Patients also should be educated about the unpredictability of death or of sudden worsening of liver disease while on the wait-list. They should be advised that there is a survival benefit associated with the transplantation of any graft, compared with continuing on the wait-list.
In addition, the current regulatory environment focuses on transplant centers’ outcomes, which may influence some centers to discourage the acceptance of less than optimal donor organs. "This may be especially relevant for low-volume transplant centers, for whom even a small number of poor outcomes ... may make a relatively large difference in the centers’ perceived performance," the researchers wrote.
Finally, wait-list candidates should be encouraged to complete their transplant work-ups as expeditiously as possible to avoid having to refuse a donor offer simply because they have not yet undergone the necessary cardiac testing or cancer screening.
This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases and the University of California, San Francisco. No financial conflicts of interest were reported.
