Korean J Gastroenterol Vol. 77 No. 1, 4-11 https://doi.org/10.4166/kjg.2020.167 pissn 1598-9992 eissn 2233-6869 REVIEW ARTICLE MELD 점수도입이후국내알코올간질환의뇌사자간이식현황 주동진 연세대학교의과대학외과학교실 Current Status of Deceased Donor Liver Transplantation for Alcoholic Liver Disease in Korea in MELD Era Dong Jin Joo Department of Surgery, Yonsei University College of Medicine, Seoul, Korea The organ allocation system should be fair and efficient to predict the prognosis of patients with end-stage organ failure. The liver allocation system in Korea was changed to the model for end-stage liver disease (MELD) score system from Child-Turcotte-Pugh score-based status system in 2016. Since then, there have been some changes in matching liver graft to recipients in deceased liver transplantation. The severity of sickness of the end-stage liver failure patients has been increased in the MELD era than before. Since 2013, liver transplantation for alcoholic liver disease has been gradually increasing in Korea. We should take proper evaluation into consideration when we decide early liver transplantation particularly for patients with severe alcoholic hepatitis, who have a high MELD score. Above all, overcoming organ shortage, it is necessary for us to try to increase the number of deceased donors to meet the need for liver transplantation for end-stage liver disease patients. (Korean J Gastroenterol 2021;77:4-11) Key Words: Liver transplantation; End stage liver disease; Liver diseases, alcoholic 서론 장기이식분야에서이식장기부족의문제는늘큰걸림돌이되고있다. 특히, 우리나라와같이뇌사장기기증이부족한나라에서는부족한장기를공정하고효율적으로분배하는일은매우중요하다. 우리나라는 2000년장기등이식에관한법률이제정되어시행된이후, Child-Turcotte-Pugh score (CTP 점수 ) 를기준으로하는응급도에따라뇌사장기기증자의간장분배를시행하였다. Status 1, 2A, 2B, 3, 7 등 5개로구분되는응급도에따라뇌사장기기증자의간장이배분되었다. 그러나 2016년 model for end-stage liver disease (MELD) 점수에 의한간장분배체계가도입되면서, 환자의중증도에따른예후를더잘반영하여간장을분배하는방향으로변화하였다 (Table 1). MELD 점수는초기에간경변으로경정맥간내문맥-정맥단락술 (transjugular intrahepatic portosystemic shunt, TIPS) 을시행받은환자에서 3개월사망률을예측하기위해만들어진것으로, 말기간부전환자의예후를반영하는예측모델로간이식의우선순위를결정하는데적합한시스템으로채택되어발전하게되었다. 1,2 그러나여러가지다양한간질환의특성을모두대변할수는없어나라마다혈중나트륨수치를추가하여변형하거나, 간암환자에게추가점수를주는등의보완적인제도를도입하고있다. 3-6 국내에서는뇌사장기기증자의수가매우부족하여이러 Received December 10, 2020. Revised January 15, 2021. Accepted January 19, 2021. CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2020. Korean Society of Gastroenterology. 교신저자 : 주동진, 03722, 서울시서대문구연세로 50-1, 연세대학교의과대학외과학교실 Correspondence to: Dong Jin Joo, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea. Tel: +82-2-2228-2131, Fax: +82-2-313-8289, E-mail: djjoo@yuhs.ac, ORCID: https://orcid.org/0000-0001-8405-1531 Financial support: None. Conflict of interest: None. Korean J Gastroenterol, Vol. 77 No. 1, January 2021 www.kjg.or.kr
Joo DJ. Current Situation of DDLT for Alcoholic Liver Disease in MELD Era 5 한변형및추가점수제도의혜택을받을수있는환자들이거의없는실정으로급성간부전으로응급도 1에해당되는경우를제외하면대부분순수한 MELD 점수로만간장분배를받게된다. 7 2019년도장기등이식및인체조직기증통계연보에따르면, 한해동안뇌사자간이식을받은환자들 391명중급성간부전이나재이식등응급도 1에해당되는경우를제외한 358명의수혜자중 69.6% 가 MELD 점수 38점이상이었다. 8 즉, 중증도가매우높은환자들에게만주로뇌사자간장이분배되고있는상황이다. 말기간부전의원인질환별로살펴보면, B형간염예방접종의보급과 C형간염에대한치료약제의발달로최근전세계적으로간이식을필요로하는원인질환의양상이조금씩변화되고있다. 미국에서는 2015년부터기존간이식의가장흔한원인질환이던 C형간염은줄어든데반해알코올간질환과비알코올지방간질환이급격히늘고있으며, 2019년미국 Organ Procurement and Transplantation Network (OPTN) 의자료를보면, 전체간이식대기등록환자중 24% 가알코올간질환이며 20% 가지방간염, 15% 가 C형간염으로보고되고있다. 9 상대적으로 B형간염이많고비알코올지방간질환이적은우리나라에서도바이러스성간질환로인한간이식은줄고있는반면, 알코올간질환으로인한간이식은점점증가하는추세에있다. 8 이에본고에서는국내 MELD 점수가도입된지 4년이지난현시점에서우리나라뇌사자간이식의현황 및그중알코올간질환의양상이어떻게변화되고있는지를살펴보고자한다. 본론 1. MELD 점수의국내도입배경및과정 2000년이전까지국내에는뇌사자장기기증에관한법률이없어정부의통제없이각의료기관에서뇌사자의관리와장기기증이이루어졌다. 그러나 2000년국내에장기등이식에관한법률이제정및시행되면서국립장기조직혈액관리원 (Korean Network for Organ Sharing, KONOS) 의관리하에뇌사자의발굴, 장기적출및장기이식이이루어지기시작하였다. 그중간이식대기환자에대해서는장기이식관리업무규정을통해정의된응급도에따라뇌사자간장의분배가이루어지고있다. 장기등이식에관한법률시행이후처음에는미국 United Network for Organ Sharing (UNOS) 의기준을참고하여 Child-Turcotte-Pugh score (CTP 점수 ) 를기준으로한응급도에따라간장분배가이루어져왔다. 말기간부전환자의예후를더정확히예측하여우선순위를결정하는모델을간장분배원칙에도입하려는많은노력들끝에 2002년미국에서는 MELD 점수를도입하여간장분배의기준을삼기시작하였다. 10 이후 MELD 점수는전세계적으로간장분배의기본원칙으로자리잡았고, 나라마다각자의사정에따라조 Table 1. Comparison Between Previous KONOS Status and Current MELD System KONOS status Status 1 Fulminant hepatic failure without underlying liver disease. Status 1 Primary non-function within 7 days. Status 2A Status 2B Status 3 Patients with chronic liver disease who had a CTP score of 10 and meet at least one of the other medical criteria (life-threatening variceal bleeding, refractory ascites/hydrothorax, hepatic encephalopathy, or hepatorenal syndrome), who were hospitalized in an intensive care unit with a life expectancy of <7 days without a liver transplant. Patients with chronic liver disease who had a CTP score of 10, or a CTP score of 7 and meet at least one of the medical criteria (life-threatening variceal bleeding, refractory ascites/hydrothorax, or spontaneous bacterial peritonitis). Patients who have a CTP score of 7 without meeting status 2B criteria MELD system Fulminant hepatic failure without underlying liver disease. (with hepatic encephalopathy occurred within 8 weeks from the first symptoms, and meet at least one condition out of ventilator care, renal replacement therapy, or INR>2.0) Primary non-function within 7 days. Wilson s disease patient with fulminant hepatic failure. Status 2 MELD: 38-40 Status 3 MELD: 31-37 Status 4 MELD: 21-30 Status 7 Waiting patients without above condition. Status 5 MELD: 6-20 KONOS, Korean Network for Organ Sharing; MELD, model for end-stage liver disease; CTP, Child-Turcotte-Pugh; INR, International Normalized Ratio. Vol. 77 No. 1, January 2021
6 주동진. MELD 이후알코올성간질환의뇌사자간이식현황 금씩변형하거나상황에따라 MELD 점수에추가점수를주는방식으로운용되고있다. 1,11-14 국내에서는 15년간 CTP 점수를근간으로하는응급도로간장분배를하였으나 CTP 점수가환자의중증도를반영하기에각단계의폭이너무넓고, 의료진의주관적판단이개입할수있다는우려가있어 MELD 점수도입에대한필요성이지속적으로제기되어왔다. 15 CTP 점수를근간으로한응급도평가와 MELD 점수간의상관성을비교한국내연구에의하면 CTP 응급도평가는일부군에서 MELD 점수의중복및역전이나타나서의학적응급도평가에제약이있는것으로보고되었다. 15,16 이에, KONOS에서간장배분의원칙으로 MELD 점수를도입하기위한연구용역과제를거쳐, MELD 시스템이국내간장응급도기준으로적합하다는결론을도출하였고, 2016년 6월부터는 MELD 점수를기준으로장기를배분하는시스템을채택하여시행중에있다. 17 2. 국내뇌사자간이식의현황 2000년장기등이식에관한법률시행이후국내뇌사장기기증자는꾸준히증가해왔으나, 여전히뇌사자장기기증은간이식대기자수에턱없이부족한것이현실이다. 국내뇌사장기기증자는최근연간 400-500명정도수준으로발생을하고있으나, 2020년 12월현재 KONOS에등록된간장대기자등록자는 6,070명이다. 18 2000년인구 100만명당국내뇌사자장기기증자는 1.1명으로미국이나유럽에비해현저히적은형편이었으나대한이식학회및 2009년설립된한국장기기증원 (Korea Organ Donation Agency, KODA) 의홍보및활동으로그수가조금씩늘어 2016년에는 11.1명까지도달하였다. 이는독일의 11.3명과비슷한수준으로아시아에서는뇌사장기기증을가장많이하고있는나라중하나가되었다. 그러나이후다소감소하여 2019년현재뇌사장기기증자는인구 100만명당 8.7명이다 (Fig. 1). 8 2019년스페인은 100만명당 49.6명, 미국은 36.1명의뇌사자가장기를기증하였고, 프랑스, 영국, 호주등도모두 100만명당 20명이상의뇌사자장기기증률을보이고있는것에비하면아직도국내뇌사장기기증자는매우부족한상황이라하겠다. 19 Fig. 2에서보듯이최근 10년동안국내간이식전체건수는해마다증가하여지난 10년간 50% 이상의성장을보였다. 2019년한해동안국내에서시행된간이식은 1,579건이다. 그중뇌사자간이식의비율은조금씩증가하여 2010년 22.7% 에서 2016년 34.5% 까지증가하였으나, 이후다소감소하여 2019년에는 24.8% 를기록하였다 (Fig. 2). 8 이렇듯전체간이식은증가하는데반해뇌사기증자가감소하고있는데에는여러가지이유가있을수있다. 그원인에대해체계적으로분석한자료는없지만, 최근 10년간급성간부전으로뇌사자간이식을받은환자의수는큰변화가없고, B형간염예방접종및항바이러스제의발달로 B형간염에의한간부전의환자수가큰폭으로줄어들고있는데반해, 간암환자를대상으로하는생체간이식은지속적으로늘고있어상대적인뇌사자비율감소가그원인이될수있을것이고, 2018년연명의료결정제도의도입이후잠재적인뇌사자가연명의료를중단함으로써장기기증으로까지이어지지못해뇌사장기기증자의수가다소감소하였을가능성도그원인중하나로조심스럽게추론해볼수있다. Fig. 1. Total number of deceased donor and the rate of deceased donor per million in Korea. The total number of deceased donors in Korea has been increasing over the last 10 years. The deceased donor rate per million in 2016 have reached up to 11.1 but thereafter the rate came down to 8.7 in 2019. The Korean Journal of Gastroenterology
Joo DJ. Current Situation of DDLT for Alcoholic Liver Disease in MELD Era 7 3. MELD 점수도입이후의국내뇌사자간이식의변화 MELD 도입이전에 CTP 점수를기반으로한 KONOS 응급도에따라뇌사자간이식을시행받은환자들의 MELD 점수를분석한국내단일기관연구결과에따르면, 16 CTP 점수와 MELD 점수는유의한상관관계를보였다. 즉, CTP 점수가높은환자들에서 MELD 점수도높게나타났다. 응급도 2A 환자들의평균 MELD 점수는 29.03±8.00이었고, 응급도 2B로간이식을시행받은환자들의평균 MELD 점수는 13.20±4.93으로유의한차이를보였다 (p<0.001). 또한, 당시응급도 2A 조건으로간이식을시행받은환자들의응급도등록조건과관련한증상 ( 복수, 간신증후군, 간성뇌증 ) 별로환자군을나누어보았을때도복수의정도, 간성뇌증의정도, 간신증후군시혈중크레아티닌의변화는 MELD 점수와유의한상관관계를보였다. 그중가장높은평균 MELD 점수를보인환자군의증상을보면간성뇌증과간신증후군이동반되어있었던환자들이었고, 그다음이간신증후군만있었던환자, 간성뇌증만있었던환자, 복수만있었던환자의순이었다. 이는혈중빌리루빈과크레아티닌에가중치를두는 MELD 점수의계산식을고려할때충분히유추할수있는결과라하겠다. 그렇지만응급도 2A보다간장배정순위가아래인응급도 2B 환자들의 MELD 점수분포와응급도 2A 환자들의각증상별 MELD 점수분포를나열하여보면, 중첩되는구간들이존재함을알수있고, 특히, 복수조건 (1주일에 4 L 이상의복수천자가필요한경우 ) 만으로응급도 2A에등록되어간이식을시행받은환자들중 36.4% 의환자들이 20점미만의 MELD 점수를보여, 응급도 2B에서 20점이상의 MELD 점수를보인 5% 의환자들보다낮은 MELD 점수에서간이식을시 행받았다 (Fig. 3). 16 다른국내기관에서시행한연구에서는 MELD 점수도입이후뇌사자간이식을받은환자들과 MELD 점수도입이전 CTP 점수로간이식을배정받은환자들을비교하였다. 7 MELD 도입이전에뇌사자간이식을시행받은환자들의평균 MELD 점수는 26.0±8.1점이었고, 도입이후에는 36.8±4.5 점으로높아졌다 (p<0.001). 두군간에이식후성적에있어서 6개월생존율에는차이를보이지않았으나, 3개월내합병증발생에있어서는 MELD 도입이후간이식을시행받은환자군에서 MELD 도입이전군에비하여높게나타났다. 대부분의합병증은감염관련합병증이었다. 이를통해 MELD 도입이후뇌사자간이식을받은환자들의중증도가이전보다더높아졌음을유추해볼수있다. 상기연구에서는 MELD 점수도입전후의원발간질환의분포에는차이가없는것으로보고하였다. 양군모두에서가장많은원발질환은알코올간질환으로, MELD 도입이전에는 30명중 12명으로전체환자의 40% 를차지하였던반면, MELD 도입이후에는 41명중 19명으로 46.3% 를보였지만통계적으로유의한차이는아니었다. KONOS 연보를바탕으로연도별뇌사자간이식수혜자의원인질환을비교해보면알코올간질환은 2014년부터급격히증가하였으며, 2016년 Fig. 2. The annual proportion of deceased donor liver transplantation. The total number of liver transplantations has been increasing annually but the proportion of the deceased donor stays around 20-30%. Black letter is total number of liver transplantation. White letter is the proportion of deceased donor liver transplantation. DDLT, deceased donor liver transplantation; LDLT, living donor liver transplantation. Fig. 3. MELD score distribution by KONOS status with different symptoms. Out of status 2A patients who underwent deceased donor liver transplantation, those who had both HEP and HRS showed the highest MELD score than other symptoms. But there was an overlapped range between status 2A and 2B group (Modified from Joo et al. 16 ) MELD, model for end-stage liver disease; KONOS, Korean Network for Organ Sharing; HEP, hepatic encephalopathy; HRS, hepatorenal syndrome. Vol. 77 No. 1, January 2021
8 주동진. MELD 이후알코올성간질환의뇌사자간이식현황 부터는 B형간염에의한간경변증등다른원인질환을제치고뇌사자간이식의첫번째원인질환이되었고그비율은해가갈수록증가하고있다 (Fig. 4). 8,18 MELD 점수도입이후, 혈액형별로뇌사자간이식수혜자들을구분해보았을때, 가장많이수혜를받은혈액형은 A형이었으나이는 MELD 시행전과후에차이는없었다. O형혈액형의경우 15명의수혜자중한명을제외하면모두 MELD 점수최고점인 40점을보인반면, A형의평균 MELD 점수는 37.3점, B형 35점과 AB형 34점으로 O형수혜자에비하여상대적으로낮은 MELD 점수를보였다. 7 O형환자의 MELD 점수가타혈액형보다상대적으로높게나타난것은 O형환자는낮은 MELD 점수에서장기가배정될가능성이낮다는것을반증하는결과다. 이는 O형수혜자는 O형기증자의장기만을받을수밖에없지만, O형기증자발생시에는다른혈액형의수혜자와경쟁을해야하는상황에서기인하는것으로해석된다. 뇌사기증자의수가어느정도까지증가하여이러한차이가상쇄되기전까지는해결이어려운문제라하겠다. 그동안뇌사자장기기증을활성화하기위한학회와정부를통한다양한노력들이있어왔지만, 앞으로더적극적인제도적인장치마련및대국민홍보가필요하리라생각된다. 4. 알코올간질환의간이식현황최근 10년간의국내간이식현황을보면, 2010년에는 B형 간염에의한간경변증이간이식의가장많은적응증이었던반면, 2019년에는알코올간질환이 B형간염으로인한간이식을역전하여생체간이식과뇌사자간이식을모두합해도가장많은간이식의적응증이되었다. 알코올간질환과간암으로인한간이식은해마다지속적인증가추세를보이고있는데반해, B형간염으로인한간이식은지속적으로감소하는양상을보이고있다. 특히 2013년이후알코올간질환의증가속도가가파르게상승하고있다 (Fig. 4A). 이러한현상은생체간이식에서도나타나는현상이지만, 뇌사자간이식에서더빠른속도로나타나고있다 (Fig. 4B). 간암을제외하면, 생체간이식에서는지난 10년간알코올간질환의비율이 6.8% 에서 15.0% 로늘어난반면, 뇌사자간이식에서는 8.3% 에서 42.7% 로크게증가하여 2019년에는뇌사자간이식의거의절반을차지하게되었다. 이에반하여그동안가장많은간이식의원인이되었던 B형간염에의한간경변증은생체간이식에서 35.4% 에서 18.6% 로크게감소하였고, 뇌사자간이식에서도 49.6% 에서 17.9% 로감소하였다. 8 이는 B형간염의예방접종및항바이러스제의효과와 C형간염의치료제개발등으로전세계적으로바이러스성간경변증환자의절대수가감소하고있으나, 알코올간질환과비알코올지방간질환환자의수가증가하는것과무관하지않은결과로해석된다. 뇌사자간이식에서알코올성간질환의비율이생체간이식에서의비율보다더높게나타나고있는이유에대해서는현 A B Fig. 4. Annual etiology changes of liver transplantation. (A) The yearly total number of liver transplantations according to the etiology of liver disease. (B) The yearly changes of liver etiology for living donor liver transplantation (upper) and deceased donor liver transplantation (lower). LT, liver transplantation; LC, liver cirrhosis; HCV, hepatitis C virus; HBV, hepatitis B virus; HCC, hepatocellular carcinoma; ALF, acute liver failure; PSC, primary sclerosing cholangitis; LDLT, living donor liver transplantation; DDLT, deceased donor liver transplantation. The Korean Journal of Gastroenterology
Joo DJ. Current Situation of DDLT for Alcoholic Liver Disease in MELD Era 9 재까지국내에보고된자료가없어정확한해석이어려우나, 우리나라와같이생체간이식을주로하는나라에서가족간의유대가다른질환군에비하여다소떨어지는알코올성간질환환자들이간경변으로인한증상이나타나도가족내생체기증자를구하지못하고내과적치료를반복하다가 MELD 점수가상승하는말기간부전에이르러서야뇌사자간이식을받게될가능성에대해서도조심스럽게고려해볼수있겠다. 또한, 중증알코올성간염환자들의 MELD 점수가높아뇌사자간이식배정에유리한부분이있다는점도고려해야할것이다. 20 그러나이에대해서는추가적인연구결과들이필요할것으로사료된다. 5. 알코올성간질환의간이식에서고려해야할점앞서언급하였듯이, 알코올간질환은서구에서는말기간부전환자의첫번째사망원인이되고있고, 21,22 국내에서도그수가점점늘고있는실정이다. 말기간부전에이른알코올간질환환자의궁극적인치료는간이식이될수밖에없으나, 알코올간질환환자에게간이식을시행함에있어우선적으로고려되어야하는것은바로금주지속여부이다. 특히뇌사기증자의장기는가족간에이루어지는생체기증자의장기와달리, 특정개인을지정하여기증되는것이아니라공공의영역에서배분이되는것이기때문에, 국가에서정해놓은 MELD 점수와같은규칙에따라공정하게배분되는것을원칙으로해야하며, 기증된간을통해건강한사회일원으로서의복귀를기대할수있어야한다. 이러한이유로, 자의로간을손상시킨알코올간질환환자에게공공의소중한자원이라할수있는뇌사기증자의장기를배정하는것이옳은지에대한윤리적문제가발생할수있다. 또한간이식후정상적인사회생활로의복귀가아닌다시음주로돌아갈수있다는우려도있어이들에대한장기이식에대해서는의학적인판단외에윤리적인잣대를가지고보는견해들도있다. 21 이러한이유로미국과캐나다등에서는간이식대기자등록전 6개월이상의금주기간을요구하고있다. 23,24 그러나이의효용성에대해서는아직도논란의대상이되고있다. 실제로간이식전금주를한기간이이식후음주의재발을정확히예측하지못한다는의견과금주의기간보다는이식전음주의양이이식후음주의재발을더잘예측한다는보고가나오는등이에대해서는명확한근거가마련되어있지않기때문이다. 25-27 국내에서는아직까지이식전금주기간에대해명문화된규정은없으며, 유럽에서도이에대한명확한규정은없는상태이다. 심지어미국이나남미에서보고된알코올간염에대한연구에서는간이식전 6개월의금주기간과간이식후재음주와의연관성이매우약하다는보고들도나오고있다. 28,29 간이식전금주기간에대해서는여전히논란의여지가있지만, 30 만 성알코올성간염환자에게서는금주를적극적으로유도하는것이필요할것으로사료되며, 간이식전금주기간의필요에대해서는간관련및이식관련학회와유관단체의지속적논의와연구가필요할것으로생각된다. 만성알코올간경변증과더불어고려해야할것은중증알코올간염에대한부분이다. 대부분알코올남용자에서급성으로나타나는황달과간기능이상을동반한중증알코올간염은항산화제및스테로이드등내과적치료를우선하는것이원칙이지만, 스테로이드치료에반응하지않는 Lille score 0.45 이상의환자들에서는간이식을고려할수밖에없는상황에놓이게된다. 31 이러한환자에서는간이식을시행하지않을경우 6개월이내의사망률이 75% 정도에이르기때문에, 약물치료에반응을하지않는중증알코올간염환자에서는조기간이식을고려할수있다. 32,33 미국알코올간염환자에대한조기간이식컨소시엄 (American Consortium of Early Liver Transplantation for Alcoholic Hepatitis, ACCELERATE-AH) 에서보고한결과에따르면, 20 6개월금주기간을갖지않고조기간이식을시행받은 147명의환자들에서간이식당시평균 MELD-Na 점수가 39점으로간이식당시의중증도가매우높았음에도간이식후 1년, 3년생존율은각각 94% 와 84% 로다른질환으로인한간이식환자의성적과비슷하였다. 그러나이환자들중 1년이내음주의재발이있었던환자는 10%, 3년이내에는 17% 였다. 음주의재발은간이식후생존에미치는위험인자분석에서유의미한위험인자로나타났다. 이연구에서는 Lille score가 0.45 이상이면서내과적치료에불응하는환자들의간이식을결정하는경우, 이식전중독전문가의면밀한검토가필요하며, 이전에알코올간염의병력이없으면서동반된의학적합병증이없는것을확인하고, 음주재발에대한충분한평가를시행한후간이식을결정하도록권고하고있다. 결론 국내의뇌사장기기증은꾸준히증가하고있지만아직까지간이식대기환자들의수요를충족하기에는매우부족한것이현실이다. 이러한상황에서 CTP 점수에비해객관적이고예후를잘반영하는 MELD 점수가간장분배의원칙으로도입되었다. MELD 점수는이전 CTP 점수를기반으로하는간이식대기자의응급도에비하여간질환의중증도를더잘반영하여 MELD 도입이후뇌사자간이식을받는환자들의중증도는더높아졌다. 국내간이식의건수가매년늘고있는중에 B형간염에의한간이식은그수가줄고있으나알코올간질환은크게늘고있다. 이러한현상은특히뇌사자간이식 Vol. 77 No. 1, January 2021
10 주동진. MELD 이후알코올성간질환의뇌사자간이식현황 에서더뚜렷하게나타나고있다. 알코올간질환환자의이식후성적은다른질환으로간이식을받은환자들에비하여나쁘지않으나, 음주가조절되지못한상태에서간이식을받게되는중증알코올간염환자에대해서는이식전충분한중독전문가의평가와이식후음주재발을방지하기위한노력이함께병행되어야할것이다. 알코올간질환환자의간이식이점점늘고있는바, 이식전간부전으로의진행을최대한방지하고, 이식을받았을경우음주의재발을막을수있는관리에대한추가적인연구및치료지침의마련이필요할것으로생각된다. 또한, MELD 도입이후에도여전히우리는장기부족으로인해이식이필요한환자들에게적절한시기에간이식을하기어려운상황에놓여있다. 따라서무엇보다장기부족의현실을극복하고, 간이식이필요한환자들에게최적의치료를제공하기위해뇌사자장기기증의활성화를위한노력에최선을다해야할것이다. REFERENCES 1. Wiesner RH, McDiarmid SV, Kamath PS, et al. MELD and PELD: application of survival models to liver allocation. Liver Transpl 2001;7:567-580. 2. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000;31:864-871. 3. Trapani S, Morabito V, Oliveti A, et al. Liver allocation in urgent MELD score 30: the italian experience. Transplant Proc 2016;48:299-303. 4. Ruf AE, Kremers WK, Chavez LL, Descalzi VI, Podesta LG, Villamil FG. 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