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Lozanovski VJ, Probst P, Arefidoust A, Ramouz A, Aminizadeh E, Nikdad M, Khajeh E, Ghamarnejad O, Shafiei S, Ali-Hasan-Al-Saegh S, Seide SE, Kalkum E, Nickkholgh A, Czigany Z, Lurje G, Mieth M, Mehrabi A. Prognostic role of the Donor Risk Index, the Eurotransplant Donor Risk Index, and the Balance of Risk score on graft loss after liver transplantation. Transpl Int 2021; 34:778-800. [PMID: 33728724 DOI: 10.1111/tri.13861] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 02/19/2021] [Accepted: 03/08/2021] [Indexed: 12/12/2022]
Abstract
This study aimed to identify cutoff values for donor risk index (DRI), Eurotransplant (ET)-DRI, and balance of risk (BAR) scores that predict the risk of liver graft loss. MEDLINE and Web of Science databases were searched systematically and unrestrictedly. Graft loss odds ratios and 95% confidence intervals were assessed by meta-analyses using Mantel-Haenszel tests with a random-effects model. Cutoff values for predicting graft loss at 3 months, 1 year, and 3 years were analyzed for each of the scores. Measures of calibration and discrimination used in studies validating the DRI and the ET-DRI were summarized. DRI ≥ 1.4 (six studies, n = 35 580 patients) and ET-DRI ≥ 1.4 (four studies, n = 11 666 patients) were associated with the highest risk of graft loss at all time points. BAR > 18 was associated with the highest risk of 3-month and 1-year graft loss (n = 6499 patients). A DRI cutoff of 1.8 and an ET-DRI cutoff of 1.7 were estimated using a summary receiver operator characteristic curve, but the sensitivity and specificity of these cutoff values were low. A DRI and ET-DRI score ≥ 1.4 and a BAR score > 18 have a negative influence on graft survival, but these cutoff values are not well suited for predicting graft loss.
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Affiliation(s)
- Vladimir J Lozanovski
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.,Liver Cancer Center Heidelberg (LCCH), University Hospital Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.,The Study Center of the German Surgical Society (SDGC), University Hospital Heidelberg, Heidelberg, Germany
| | - Alireza Arefidoust
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ehsan Aminizadeh
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Mohammadsadegh Nikdad
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Omid Ghamarnejad
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Saeed Shafiei
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Sadeq Ali-Hasan-Al-Saegh
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Svenja E Seide
- Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, Heidelberg, Germany
| | - Eva Kalkum
- The Study Center of the German Surgical Society (SDGC), University Hospital Heidelberg, Heidelberg, Germany
| | - Arash Nickkholgh
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Georg Lurje
- Department of Surgery, Charité -Universitätsmedizin Berlin, Berlin, Germany
| | - Markus Mieth
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.,Liver Cancer Center Heidelberg (LCCH), University Hospital Heidelberg, Heidelberg, Germany
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2
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Effects of Intraoperative Fluid Balance During Liver Transplantation on Postoperative Acute Kidney Injury: An Observational Cohort Study. Transplantation 2020; 104:1419-1428. [PMID: 31644490 DOI: 10.1097/tp.0000000000002998] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver transplant recipients suffer many postoperative complications. Few studies evaluated the effects of fluid management on these complications. We conducted an observational cohort study to evaluate the association between intraoperative fluid balance and postoperative acute kidney injury (AKI) and other postoperative complications. METHODS We included consecutive adult liver transplant recipients who had their surgery between July 2008 and December 2017. Our exposure was intraoperative fluid balance, and our primary outcome was the grade of AKI at 48 hours after surgery. Our secondary outcomes were the grade of AKI at 7 days, the need for postoperative renal replacement therapy, postoperative red blood cell transfusions, time to first extubation, time to discharge from the intensive care unit (ICU), and 1-year survival. Every analysis was adjusted for potential confounders. RESULTS We included 532 transplantations in 492 patients. We observed no effect of fluid balance on either 48-hour AKI, 7-day AKI, or on the need for postoperative renal replacement therapy after adjustments for confounders. A higher fluid balance increased the time to ICU discharge, and increased the risk of dying (hazard ratio = 1.21 [1.04,1.40]). CONCLUSIONS We observed no association between intraoperative fluid balance and postoperative AKI. Fluid balance was associated with longer time to ICU discharge and lower survival. This study provides insight that might inform the design of a clinical trial on fluid management strategies in this population.
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3
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Machine-Learning Algorithms Predict Graft Failure After Liver Transplantation. Transplantation 2017; 101:e125-e132. [PMID: 27941428 DOI: 10.1097/tp.0000000000001600] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The ability to predict graft failure or primary nonfunction at liver transplant decision time assists utilization of scarce resource of donor livers, while ensuring that patients who are urgently requiring a liver transplant are prioritized. An index that is derived to predict graft failure using donor and recipient factors, based on local data sets, will be more beneficial in the Australian context. METHODS Liver transplant data from the Austin Hospital, Melbourne, Australia, from 2010 to 2013 has been included in the study. The top 15 donor, recipient, and transplant factors influencing the outcome of graft failure within 30 days were selected using a machine learning methodology. An algorithm predicting the outcome of interest was developed using those factors. RESULTS Donor Risk Index predicts the outcome with an area under the receiver operating characteristic curve (AUC-ROC) value of 0.680 (95% confidence interval [CI], 0.669-0.690). The combination of the factors used in Donor Risk Index with the model for end-stage liver disease score yields an AUC-ROC of 0.764 (95% CI, 0.756-0.771), whereas survival outcomes after liver transplantation score obtains an AUC-ROC of 0.638 (95% CI, 0.632-0.645). The top 15 donor and recipient characteristics within random forests results in an AUC-ROC of 0.818 (95% CI, 0.812-0.824). CONCLUSIONS Using donor, transplant, and recipient characteristics known at the decision time of a transplant, high accuracy in matching donors and recipients can be achieved, potentially providing assistance with clinical decision making.
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Neves DB, Rusi MB, Diaz LGG, Salvalaggio P. Primary graft dysfunction of the liver: definitions, diagnostic criteria and risk factors. ACTA ACUST UNITED AC 2016; 14:567-572. [PMID: 27783749 DOI: 10.1590/s1679-45082016rw3585] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 04/09/2016] [Indexed: 12/11/2022]
Abstract
Primary graft dysfunction is a multifactorial syndrome with great impact on liver transplantation outcomes. This review article was based on studies published between January 1980 and June 2015 and retrieved from PubMed database using the following search terms: "primary graft dysfunction", "early allograft dysfunction", "primary non-function" and "liver transplantation". Graft dysfunction describes different grades of graft ischemia-reperfusion injury and can manifest as early allograft dysfunction or primary graft non-function, its most severe form. Donor-, surgery- and recipient-related factors have been associated with this syndrome. Primary graft dysfunction definition, diagnostic criteria and risk factors differ between studies. RESUMO A disfunção primária do enxerto hepático é uma síndrome multifatorial com grande impacto no resultado do transplante de fígado. Foi realizada uma ampla revisão da literatura, consultando a base de dados PubMed, em busca de estudos publicados entre janeiro de 1980 e junho de 2015. Os termos descritivos utilizados foram: "primary graft dysfunction", "early allograft dysfunction", "primary non-function" e "liver transplantation". A disfunção traduz graus diferentes da lesão de isquemia e reperfusão do órgão, e pode se manifestar como disfunção precoce ou, na forma mais grave, pelo não funcionamento primário do enxerto. Fatores relacionados ao doador, ao transplante e ao receptor contribuem para essa síndrome. Existem definições diferentes na literatura quanto ao diagnóstico e aos fatores de risco associados à disfunção primária.
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Affiliation(s)
- Douglas Bastos Neves
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brazil; Hospital São Vicente de Paulo, Rio de Janeiro, RJ, Brazil.,Programa de Pós-graduação em Ciências da Saúde, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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5
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Stine JG, Argo CK, Pelletier SJ, Maluf DG, Northup PG. Liver transplant recipients with portal vein thrombosis receiving an organ from a high-risk donor are at an increased risk for graft loss due to hepatic artery thrombosis. Transpl Int 2016; 29:1286-1295. [PMID: 27714853 DOI: 10.1111/tri.12855] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/23/2016] [Accepted: 09/02/2016] [Indexed: 12/11/2022]
Abstract
We hypothesize that recipients with pretransplant portal vein thrombosis (PVT) receiving organs from high-risk donors (HRD) are at an increased risk of HAT. Data on all liver transplants in the United States from February 2002 to March 2015 were analyzed. Recipients were sorted into two groups: those with PVT and those without. HRDs were defined by donor risk index (DRI) >1.7. Multivariable logistic regression models were constructed to assess the independent risk factors for HAT with the resultant graft loss ≤90 days from transplantation. A total of 60 404 candidates underwent liver transplantation; of those recipients, 623 (1.0%) had HAT, of which 66.0% (n = 411) received organs from HRDs compared with 49.3% (n = 29 473) in recipients without HAT (P < 0.001); 2250 (3.7%) recipients had pretransplantation PVT and received organs from HRDs. On adjusted multivariable analysis, PVT with a HRD organ was the most significant independent risk factor (OR 3.56, 95% CI 2.52-5.02, P < 0.001) for the development of HAT. Candidates with pretransplant PVT who receive an organ from a HRD are at the highest risk for postoperative HAT independent of other measurable factors. Recipients with pretransplant PVT would benefit from careful donor selection and possibly anticoagulation perioperatively.
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Affiliation(s)
- Jonathan G Stine
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for the Study of Coagulation Disorders in Liver Disease, University of Virginia, Charlottesville, VA, USA
| | - Curtis K Argo
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for the Study of Coagulation Disorders in Liver Disease, University of Virginia, Charlottesville, VA, USA
| | - Shawn J Pelletier
- Division of Transplant, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Daniel G Maluf
- Division of Transplant, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Patrick G Northup
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for the Study of Coagulation Disorders in Liver Disease, University of Virginia, Charlottesville, VA, USA
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6
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Morise Z, Kawabe N, Tomishige H, Nagata H, Kawase J, Arakawa S, Yoshida R, Isetani M. Recent advances in the surgical treatment of hepatocellular carcinoma. World J Gastroenterol 2014; 20:14381-14392. [PMID: 25339825 PMCID: PMC4202367 DOI: 10.3748/wjg.v20.i39.14381] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 05/25/2014] [Accepted: 07/16/2014] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. The treatment of HCC is complex and complicated by the severity of associated chronic liver disease, the stage of HCC, and the clinical condition of the patient. Liver resection (LR) is one of the most efficient treatments for patients with HCC, with an expected 5-year survival of 38%-61% depending on the stage of the disease. Improved liver function assessment, increased understanding of segmental liver anatomy from advanced imaging studies, and surgical technical progress are important factors that have led to reduced mortality in patients with HCC. The indication for LR may be expanded due to emerging evidences from laparoscopic hepatectomies and combined treatments with newly developed chemotherapies. Liver transplantation (LT) is considered as an ideal treatment for removal of existing tumors and the injured/preneoplastic underlying liver tissue with impaired liver function and the risk of multicentric carcinogenesis that results from chronically injured liver. However, LT is restricted to patients with minimal risk of tumor recurrence under immunosuppression. The expansion of criteria for LT in HCC patients is still under trial and discussion. Limited availability of grafts, as well as the risk and the cost of transplantation have led to considerable interest in expansion of the donor pool, living donor-related transplantation, and combined treatment involving LR and LT. This highlight presents evidence concerning recent studies evaluating LR and LT in HCC patients. In addition, alternative therapies for the treatment of early stage tumors and the management of patients on transplant waiting lists are discussed.
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7
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Malinis MF, Chen S, Allore HG, Quagliarello VJ. Outcomes among older adult liver transplantation recipients in the model of end stage liver disease (MELD) era. Ann Transplant 2014; 19:478-87. [PMID: 25256592 DOI: 10.12659/aot.890934] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Since 2002, the Model of End Stage Liver Disease (MELD) score has been the basis of the liver transplant (LT) allocation system. Among older adult LT recipients, short-term outcomes in the MELD era were comparable to the pre-MELD era, but long-term outcomes remain unclear. MATERIAL AND METHODS This is a retrospective cohort study using the UNOS data on patients age ≥ 50 years who underwent primary LT from February 27, 2002 until October 31, 2011. RESULTS A total of 35,686 recipients met inclusion criteria. The cohort was divided into 5-year interval age groups. Five-year over-all survival rates for ages 50-54, 55-59, 60-64, 65-69, and 70+ were 72.2%, 71.6%, 69.5%, 65.0%, and 57.5%, respectively. Five-year graft survival rates after adjusting for death as competing risk for ages 50-54, 55-59,60-64, 65-69 and 70+ were 85.8%, 87.3%, 89.6%, 89.1% and 88.9%, respectively. By Cox proportional hazard modeling, age ≥ 60, increasing MELD, donor age ≥ 60, hepatitis C, hepatocellular carcinoma (HCC), dialysis and impaired pre-transplant functional status (FS) were associated with increased 5-year mortality. Using Fine and Gray sub-proportional hazard modeling adjusted for death as competing risk, 5-year graft failure was associated with donor age ≥ 60, increasing MELD, hepatitis C, HCC, and impaired pre-transplant FS. CONCLUSIONS Among older LT recipients in the MELD era, long-term graft survival after adjusting for death as competing risk was improved with increasing age, while over-all survival was worse. Donor age, hepatitis C, and pre-transplant FS represent potentially modifiable risk factors that could influence long-term graft and patient survival.
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Affiliation(s)
- Maricar F Malinis
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, USA
| | - Shu Chen
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, USA
| | - Heather G Allore
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, USA
| | - Vincent J Quagliarello
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, USA
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8
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Bruzzone P, Giannarelli D, Adam R. A preliminary European Liver and Intestine Transplant Association-European Liver Transplant Registry study on informed recipient consent and extended criteria liver donation. Transplant Proc 2014; 45:2613-5. [PMID: 24034004 DOI: 10.1016/j.transproceed.2013.07.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The European Liver and Intestine Transplant Association (ELITA) and the European Liver Transplant Registry (ELTR) coordinated the distribution to European liver transplantation centers of an electronic questionnaire, developed by the first author, concerning the definition of extended criteria liver donation (ECD) and the implication for informed consent of transplant recipients. Completed questionnaires were received from 35 centers. All centers accepted ECD liver donors. The criteria for defining a liver donor as ECD were as follows: steatosis in 33 centers (94%); age up to 80 years in 15 centers (43%); serum sodium >165 mmol/L in 25 centers (71%); intensive care unit (ICU) stay with ventilation longer than 7 days in 17 centers (48%); aspartate aminotransferase (AST) >90 U/L, in 6 centers (17%); body mass index (BMI) >30 in 19 centers (54%); alanine aminotransferase (ALT) >105 U/L in 8 centers (23%); serum bilirubin >3 mg/dL in 15 centers (43%); and all criteria together in 2 centers (6%). Thirty-one centers informed the transplantation candidate of the ECD status of the donor, 20 (65%) when the patient registered for transplantation, 1 (3%) when an ECD liver became available, and 10 centers (32%) on both occasions. Thirteen centers required the liver transplantation candidate to sign a special consent form. Twenty centers informed the potential recipient of the donor's serology. Only 6 centers informed the potential recipient of any high-risk behavior of the donor.
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Affiliation(s)
- P Bruzzone
- Sapienza Università di Roma, "Azienda Policlinico Umberto l", Rome, Italy.
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9
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Mataya L, Aronsohn A, Thistlethwaite R, Ross LF. Decision making in liver transplantation--limited application of the liver donor risk index. Liver Transpl 2014; 20:831-7. [PMID: 24692309 PMCID: PMC4072766 DOI: 10.1002/lt.23879] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/28/2014] [Indexed: 02/06/2023]
Abstract
The liver donor risk index (LDRI), originally developed in 2006 by Feng et al. and since modified, is a method of evaluating liver grafts from deceased donors through the determination of the relative risk of graft failure after transplantation. Online and paper surveys about attitudes and practices regarding decision making in liver transplantation and the role of the LDRI were sent to liver transplant physicians. One hundred forty-seven of 401 eligible respondents (37%) returned partial or complete surveys. The majority of the respondents were male (116/134 or 87%) and practiced in academic medical centers (128/138 or 93%). Transplant coordinators initially contacted the candidate with an offer in 81% of the programs. Eighty-eight of 143 respondents (62%) reported that they were very familiar with the LDRI, but the vast majority (114/137 or 83%) rarely or never discussed the concept of the LDRI with their patients. A majority of the respondents (96/132 or 73%) believed that the LDRI does not adequately describe a liver's relative risk of graft failure and that there are factors making the LDRI potentially misleading (122/138 or 88%). Nevertheless, 60 of 130 respondents (46%) believed that the LDRI would increase/improve shared decision making. The LDRI has not been widely adopted because of concerns that (1) it does not accurately reflect posttransplant survival, (2) it excludes relevant donor and recipient factors, and (3) it is too complicated for candidates to grasp. There is a need to improve it or to develop other decision-making tools to help promote shared decision making. There is also great diversity in how liver offers are made to ambulatory candidates and in how transplant programs address a candidate's refusal. Research is needed to determine evidence-based best practice.
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Affiliation(s)
- Leslie Mataya
- second year medical student at the University of Chicago Pritzker School of Medicine
| | | | | | - Lainie Friedman Ross
- Carolyn and Matthew Bucksbaum Professor of Clinical Medical Ethics, Professor in the Departments of Medicine, Pediatrics and Surgery; and Associate Director of the MacLean Center for Clinical Medical Ethics, University of Chicago
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10
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Bruns H, Lozanovski VJ, Schultze D, Hillebrand N, Hinz U, Büchler MW, Schemmer P. Prediction of postoperative mortality in liver transplantation in the era of MELD-based liver allocation: a multivariate analysis. PLoS One 2014; 9:e98782. [PMID: 24905210 PMCID: PMC4048202 DOI: 10.1371/journal.pone.0098782] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 05/06/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND AIMS Liver transplantation is the only curative treatment for end-stage liver disease. While waiting list mortality can be predicted by the MELD-score, reliable scoring systems for the postoperative period do not exist. This study's objective was to identify risk factors that contribute to postoperative mortality. METHODS Between December 2006 and March 2011, 429 patients underwent liver transplantation in our department. Risk factors for postoperative mortality in 266 consecutive liver transplantations were identified using univariate and multivariate analyses. Patients who were <18 years, HU-listings, and split-, living related, combined or re-transplantations were excluded from the analysis. The correlation between number of risk factors and mortality was analyzed. RESULTS A labMELD ≥20, female sex, coronary heart disease, donor risk index >1.5 and donor Na+>145 mmol/L were identified to be independent predictive factors for postoperative mortality. With increasing number of these risk-factors, postoperative 90-day and 1-year mortality increased (0-1: 0 and 0%; 2: 2.9 and 17.4%; 3: 5.6 and 16.8%; 4: 22.2 and 33.3%; 5-6: 60.9 and 66.2%). CONCLUSIONS In this analysis, a simple score was derived that adequately identified patients at risk after liver transplantation. Opening a discussion on the inclusion of these parameters in the process of organ allocation may be a worthwhile venture.
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Affiliation(s)
- Helge Bruns
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Vladimir J Lozanovski
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Daniel Schultze
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Norbert Hillebrand
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Ulf Hinz
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Markus W Büchler
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Peter Schemmer
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
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11
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Miller-Matero LR, Eshelman A, Paulson D, Armstrong R, Brown KA, Moonka D, Abouljoud M. Beyond survival: how well do transplanted livers work? A preliminary comparison of standard-risk, high-risk, and living donor recipients. Clin Transplant 2014; 28:691-8. [PMID: 24654861 DOI: 10.1111/ctr.12368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2014] [Indexed: 12/17/2022]
Abstract
To help decrease mortality on the liver transplant waitlist, transplant centers are using living donors (LD) and high-risk donors (HRD) in addition to standard-risk donors (SRD). HRD is defined as having a donor risk index score higher than 1.6, which suggests a great risk of graft failure. Recent studies have examined survival rates between HRD and SRD recipients; however, little is known about outcomes other than survival, specifically psychosocial outcomes. The purpose of this preliminary, prospective study was to compare post-transplant psychosocial and recovery outcomes between SRD and LD and HRD liver recipients. These outcomes include cognitive functioning, psychological distress, quality of life, and self-reported and objective measures of recovery. Eighty-four patients provided baseline and six-month post-transplant data. There were generally no statistically significant differences at baseline or the six-month follow-up, suggesting that patients receiving HRD livers have similar outcomes to those who receive SRD livers. However, some effect sizes suggest potential advantages for LD recipients compared to SRD recipients. Transplant centers may be more willing to encourage patients to accept HRD or LD livers knowing that they may have comparable outcomes to SRD recipients, which also has implications for the transplant waitlist.
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12
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Ponziani FR, Zocco MA, Senzolo M, Pompili M, Gasbarrini A, Avolio AW. Portal vein thrombosis and liver transplantation: implications for waiting list period, surgical approach, early and late follow-up. Transplant Rev (Orlando) 2014; 28:92-101. [PMID: 24582320 DOI: 10.1016/j.trre.2014.01.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 09/19/2013] [Accepted: 01/19/2014] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis (PVT) is a well-known and relatively common complication of liver cirrhosis. In the past, PVT was considered as a contraindication for liver transplantation (LT). To characterize prevalence, risk factors, perioperative management and outcome of PVT in the setting of LT, the English literature published between 1991 and 2011 was reviewed. Of 6807 articles, 280 were selected, and 39 experiences were analyzed in detail (methodology, type and duration of treatments, peri-operative management, strategy to avoid recurrence, strengths and weaknesses, Oxford evidence level, citations). 3/39 studies were prospective; 9/39 were based on prospectively recorded databases; no studies of 1, 2a, 3a level of evidence were present; 5/39 were recognized as level 2b, 23/39 as level 3b, and 8/39 as level 4. High complication rate has been reported with consequent effect on graft and patient survival. Overall, PVT presents today good results similar to those obtained in patients without PVT undergoing LT even if they require a higher transfusion number and a longer ICU/hospital stay. Reported cases were retrospectively stratified according to Yerdel classification. Grade 1-2 patients (76%) do well with eversion thromboendovenectomy, resection of damaged vein and porto-portal anastomosis. Results of patients with grade 3-4 (24%) are inferior, however data on outcome in this subsets are fragmented and do not allow a reliable analysis. Moreover, results obtained in grade 3-4 cases are better in transplant centers with large specific experience. The small number of reports suggests caution. The role of anticoagulant treatment is still debated. Although in cirrhotics with PVT LT remains a demanding procedure, PVT should not be considered a contraindication anymore.
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Affiliation(s)
- Francesca Romana Ponziani
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy.
| | - Maria Assunta Zocco
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Marco Senzolo
- Department of surgical, Oncological, and Gastroenterological Sciences University hospital of Padua, Padua, Italy
| | - Maurizio Pompili
- Department of Internal Medicine, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Alfonso Wolfango Avolio
- Department of Surgical Sciences, Division of General Surgery and Organs Transplantation, Catholic University, Agostino Gemelli Hospital, Rome, Italy
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13
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Pompili M, Francica G, Ponziani FR, Iezzi R, Avolio AW. Bridging and downstaging treatments for hepatocellular carcinoma in patients on the waiting list for liver transplantation. World J Gastroenterol 2013; 19:7515-7530. [PMID: 24282343 PMCID: PMC3837250 DOI: 10.3748/wjg.v19.i43.7515] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 09/30/2013] [Accepted: 10/18/2013] [Indexed: 02/06/2023] Open
Abstract
Several therapeutic procedures have been proposed as bridging treatments for patients with hepatocellular carcinoma (HCC) awaiting liver transplantation (LT). The most used treatments include transarterial chemoembolization and radiofrequency ablation. Surgical resection has also been successfully used as a bridging procedure, and LT should be considered a rescue treatment in patients with previous HCC resection who experience tumor recurrence or post-treatment severe decompensation of liver function. The aims of bridging treatments include decreasing the waiting list dropout rate before transplantation, reducing HCC recurrence after transplantation, and improving post-transplant overall survival. To date, no data from prospective randomized studies are available; however, for HCC patients listed for LT within the Milan criteria, prolonging the waiting time over 6-12 mo is a risk factor for tumor spread. Bridging treatments are useful in containing tumor progression and decreasing dropout. Furthermore, the response to pre-LT treatments may represent a surrogate marker of tumor biological aggressiveness and could therefore be evaluated to prioritize HCC candidates for LT. Lastly, although a definitive conclusion can not be reached, the experiences reported to date suggest a positive impact of these treatments on both tumor recurrence and post-transplant patient survival. Advanced HCC may be downstaged to achieve and maintain the current conventional criteria for inclusion in the waiting list for LT. Recent studies have demonstrated that successfully downstaged patients can achieve a 5-year survival rate comparable to that of patients meeting the conventional criteria without requiring downstaging.
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Sela N, Croome KP, Chandok N, Marotta P, Wall W, Hernandez-Alejandro R. Changing donor characteristics in liver transplantation over the last 10 years in Canada. Liver Transpl 2013; 19:1236-44. [PMID: 23913790 DOI: 10.1002/lt.23718] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 07/18/2013] [Indexed: 02/07/2023]
Abstract
Liver donor characteristics have a significant impact on graft quality and, in turn, recipient outcomes. In this study, we examined deceased liver donor characteristics and donor risk index (DRI) trends in Canada over the past decade. Data were extracted from the Canadian Organ Replacement Register and Transplant Québec for the decade (2000-2010). Trends in the DRI and donor characteristics, including age, race, height, cause of death (COD), location, cold ischemia time (CIT), and type of donation, were examined. In all, 3746 transplants using deceased liver donors were analyzed. The age of donors, the proportion of black donors, the proportion of cerebrovascular accidents as the COD, and the proportion of donation after cardiac death (DCD) donors all increased over the aforementioned time period. The proportion of transplants classified geographically as local increased, and the CIT for donor livers decreased. Although many of the parameters adversely affecting the DRI increased over the study period, the DRI showed only a slightly significant trend of increasing. The increase in these parameters was counteracted by a decrease in modifiable risk factors such as the CIT and distance traveled. The 5-year recipient survival rate increased from 71.43% (1999-2001) to 75.50% (2005-2007); however, this trend was not significant. Although there was an increase in the use of older and DCD organs, recipient survival was not compromised. In conclusion, demographic trends for liver donors in Canada suggest an increase in the use of higher risk donors. However, the overall graft quality has been not compromised because of a decreasing trend for the CIT and an increase in local transplants. Better coordination and allocation practices in liver transplantation across Canada have minimized the risk of graft failure and resulted in good recipient outcomes.
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Stey A, Doucette J, Florman S, Emre S. Donor and Recipient Factors Predicting Time to Graft Failure Following Orthotopic Liver Transplantation: A Transplant Risk Index. Transplant Proc 2013; 45:2077-82. [DOI: 10.1016/j.transproceed.2013.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Uemura T, Nikkel LE, Hollenbeak CS, Ramprasad V, Schaefer E, Kadry Z. How can we utilize livers from advanced aged donors for liver transplantation for hepatitis C? Transpl Int 2012; 25:671-9. [DOI: 10.1111/j.1432-2277.2012.01474.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Taner CB, Ung RL, Rosser BG, Aranda-Michel J. Age is not a contraindication for orthotopic liver transplantation: a single institution experience with recipients older than 75 years. Hepatol Int 2011; 6:403-7. [PMID: 21688082 DOI: 10.1007/s12072-011-9286-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 06/03/2011] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Transplant community has arbitrary age limit for liver transplantation based on the increased comorbidities in aging population. There has been an increased demand to consider older patients to have access to liver transplantation as the US population continues to live longer with better health. METHODS This is a single institution, retrospective review of patients, who were age 75 or over underwent liver transplantation. RESULTS There were 13 patients, who were 75 years or older at the time of orthotopic liver transplantation. There were no intraoperative or perioperative deaths. Seven of 13 patients are still alive (53.8%) with a mean survival of 65 months. CONCLUSION Our study demonstrates that a with proper evaluation and careful consideration of risk factors, individuals older than 75 years of age can undergo this life-saving procedure with acceptable long-term survival.
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Affiliation(s)
- C Burcin Taner
- Department of Transplantation, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
| | - Ryan L Ung
- Department of Transplantation, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Barry G Rosser
- Department of Transplantation, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Jaime Aranda-Michel
- Department of Transplantation, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
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Bruzzone P, Giannarelli D, Nunziale A, Manna E, Coiro S, De Lucia F, Frattaroli F, Pappalardo G. Extended Criteria Liver Donation and Transplant Recipient Consent: The European Experience. Transplant Proc 2011; 43:971-3. [DOI: 10.1016/j.transproceed.2011.01.145] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Palmiero HOM, Kajikawa P, Boin IFSF, Coria S, Pereira LA. Liver recipient survival rate before and after model for end-stage liver disease implementation and use of donor risk index. Transplant Proc 2011; 42:4113-5. [PMID: 21168639 DOI: 10.1016/j.transproceed.2010.09.092] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 09/22/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND The progressive increase in the demand for liver transplantation has led to changes in donor selection and allocation, such as the Model for End-Stage Liver Disease Score (MELD). Characteristics related to the donor, recipient, and transplantation procedure influence the results. The use of expanded-criteria donors (ECDs) and the donor risk index (DRI) are strategies that have been proposed to increase the donors pool. OBJECTIVE We sought to study liver recipient survival before and after MELD implementation as well as the use of DRI. METHODS This retrospective study of prospectively collected data analyzed 1,786 liver recipients and their donors according to gender, age, cause of brain death, intensive care unit time, split liver, infection, ECD, cardiac arrest, cold ischemia time, waiting list time, and donor origin. MELD (without special scoring) and DRI were calculated from the recorded data. The periods of this study were 2004-2006 (pre-MELD) and 2006-2008 (post-MELD). For survival times, we performed the Kaplan-Meier method with log-rank tests and Cox regression analysis (prediction). The Kolmogorov-Sminorv test was used for sample comparisons. RESULTS The 1-year survivals were similar in the 2 periods (65.4% vs 67.6%). The predictive factors for death among the whole population were DRI >1.5, cold ischemia time ≥9 hours, MELD ≥25, female recipient, and longer waiting list time. CONCLUSIONS MELD is an important tool for allocation, resulting in a reduced waiting list, increased number of split-liver procedures, and use of ECDs without deterioration of survival times. DRI >1.7 was associated with shorter survival.
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Prediction of graft dysfunction based on extended criteria donors in the model for end-stage liver disease score era. Transplantation 2010; 90:530-9. [PMID: 20581766 DOI: 10.1097/tp.0b013e3181e86b11] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND To explain the influence of recipient status combined with the accumulation of extended criteria donor (ECD) variables on the appearance of severe ischemia-reperfusion injury and graft survival in a model for end-stage liver disease (MELD)-based system, we analyzed our most recent consecutive liver transplantations (LTs), dividing them into two periods: 400 LTs (1992-2002; pre-MELD era) and 275 LTs (2002-2007; post-MELD era). METHODS Primary dysfunction (PD) was defined as primary graft failure that required emergency retransplantation or as initial poor function. Donor variables were included in a regression model to assess the probability of PD. RESULTS Donor age, macrovesicular steatosis more than 30%, and cold ischemia time were associated with allograft dysfunction. Mean probability of PD was 14.8%, 19.2%, 27.5%, and 37.4% for ECD 0, 1, 2, and more than or equal to 3, respectively (P=0.003). Distribution of no-mild, moderate, and severe ischemia-reperfusion injuries among MELD categories was 72.53%, 24.17%, and 3.30% (MELD group=12-19); 56.52%, 36.96%, and 6.5% (MELD group=20-28); and 23.91%, 54.35%, and 21.74% (MELD group >or=29), respectively (P=0.043). The development of PD according to ECD variables was 18.8%, 18.1%, 28.0%, and 35.3% for ECD 0, 1, 2, and more than or equal to 3, respectively (P=0.047). These variables were independent predictors of PD (Cox proportional regression model): ECD 2 (relative risk [RR]=1.59; 95% confidence interval [CI]=1.25-1.62), ECD 3 (RR=2.74; 95% CI=2.38-3.13), MELD 21 to 30 (RR=1.89; 95% CI=1.32-2.06), and MELD more than or equal to 30 (RR=3.38; 95% CI=2.43-3.86). Graft survival decreased, whereas MELD and the number of ECD variables increased. CONCLUSION The combination of three or more ECD variables and an MELD more than or equal to 29 is the worst scenario for graft success after LT.
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Watt KDS, Coss E, Pedersen RA, Dierkhising R, Heimbach JK, Charlton MR. Pretransplant serum troponin levels are highly predictive of patient and graft survival following liver transplantation. Liver Transpl 2010; 16:990-8. [PMID: 20677290 DOI: 10.1002/lt.22102] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Optimizing the utility of liver transplantation requires the identification of factors that confer increased risk of posttransplant mortality. Elevated serum troponin (TN) levels are strongly predictive of posttransplant mortality after kidney transplantation. We sought to determine whether pretransplant TN levels were predictive of mortality and graft loss after liver transplantation in 236 liver transplant recipients from 1998 to 2001 with 8.2 years of follow-up. Elevated TN levels [hazard ratio (HR) = 2.19, P = 0.004] and a pretransplant history of cardiovascular disease (CVD; HR = 1.90, P = 0.031) were predictive of patient mortality. Elevated TN levels (HR = 2.44, P < 0.001), a history of CVD (HR = 1.83, P = 0.031), and a combination of elevated TN levels and CVD (HR = 2.75, P = 0.027) were associated with increased graft loss. Multivariate analysis confirmed TN and CVD as independent predictors of mortality and graft loss. CVD (HR = 2.39, P = 0.032) and a combination of elevated TN levels and a history of CVD (HR = 6.67, P < 0.001) were predictive of graft loss within 1 year. Age, smoking, diabetes, hypertension, obesity, creatinine levels, and Model for End-Stage Liver Disease scores were not predictive of posttransplant mortality or graft loss. In summary, elevated pretransplant serum TN levels are strongly predictive of mortality and graft loss after liver transplantation and may be helpful in risk stratification of potential liver transplant recipients.
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Lai Q, Molinaro A, Mennini G, Nudo F, Morabito V, Corradini SG, Novelli G, Berloco P, Rossi M. Preoperative Donor Scores and Postoperative Early Measures of Graft Function: Relevance to the Outcome of Liver Transplantation. Transplant Proc 2010; 42:1209-11. [PMID: 20534263 DOI: 10.1016/j.transproceed.2010.04.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Abstract
AIM: To evaluate different standard liver volume (SLV) formula and verify the applicability of the formulae for Chinese adults.
METHODS: Data from 70 cases of living donor liver transplantation (LDLT) performed at our transplantation centers between January 2008 and April 2009 were analyzed. SLV was estimated using our recently reported formula [the Chengdu formula: SLV (mL) = 11.5 × body weight (kg) + 334] and other reported formulae used for Chinese adults. Actual intraoperative liver volumes were obtained from a review of the patients’ medical records.
RESULTS: The actual right liver volume was not significantly different from the estimated right liver volume determined by the Chengdu formula, but was significantly smaller than estimates using the Heinemann, Urata, Vauthey, and Lee formulae (P < 0.01), and significantly larger than estimates using the Fan formula (P < 0.05).
CONCLUSION: The Chengdu formula was demonstrated to be reliable by its application in LDLT.
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Colmenero J, Castro-Narro G, Navasa M. [The value of MELD in the allocation of priority for liver transplantation candidates]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 33:330-6. [PMID: 19631411 DOI: 10.1016/j.gastrohep.2009.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Accepted: 04/27/2009] [Indexed: 12/28/2022]
Abstract
Liver transplantation is the most effective treatment for many patients with chronic end-stage liver disease. The discrepancy between the number of donor organs and potential recipients causes marked pre-transplantation mortality and consequently optimal rationalization of organ allocation is essential. The Model for End-Stage Liver Disease (MELD) is an objective and easily reproducible prognostic index of mortality based on three simple analytical variables: bilirubin and serum creatinine and the prothrombin time/International Normalized Ratio (INR) of protrombine time. The implementation of MELD as an organ allocation system has reduced mortality on the waiting list without affecting post-transplantation survival. Nevertheless, this model has some limitations and consequently further investigations should be performed to improve the organ allocation policy in liver transplantation.
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Affiliation(s)
- Jordi Colmenero
- Unitat de Trasplantament Hepàtic, Servei d'Hepatologia, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, Barcelona, España.
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