Orthotopic Liver Transplantation in High-Risk Patients (original) (raw)
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521 Patients Surviving at Least 10 Years Post Liver Transplantation: Long Term Complications
Journal of Hepatology, 2011
Results: Median Donor Risk Index (DRI) was 1.66 (range 0.88-2.53) in compensated and 1.55 (0.86-2.68) in decompensated patients, regardless of HCV status (p = 0.0139). Among compensated patients median DRI was 1.64 (0.92-2.53) in HCV positive and 1.69 (range 0.88-2.34) in HCV negative recipients (p = 0.3498). Among decompensated patients median DRI was 1.53 (0.86-2.67) in HCV positive and 1.58 (0.86-2.68) in HCV negative recipients (p = 0.1821). Two-year graft survival was significantly better in HCV negative than HCV positive compensated HCC patients (0.88, s.e. = 0.035 vs 0.78, s.e. = 0.033, log rank p = 0.011). In contrast, in decompensated patients graft survival did not differ between patients with or without HCV (0.78, s.e. = 0.039 vs 0.79, s.e. = 0.041, log rank p = 0.5067). At Cox regression, HCV positivity and donor age were the only predictors of graft failure among compensated (
Risk index for early infections following living donor liver transplantation
Archives of Medical Science
Introduction: Post-operative infections in patients undergoing living donor liver transplantation (LDLT) are a major cause of morbidity and mortality. This study aims to develop a practical and efficient prognostic index for early identification and possible prediction of post-transplant infections using risk factors identified by multivariate analysis. Material and methods: One hundred patients with post-hepatitic cirrhosis, HCV positive, genotype 4, Child B/C or MELD score 13-25 undergoing LDLT were included. All potential predictors of infection were analyzed by backward logistic regression. Cutoff values were obtained from ROC curve analysis. Significant predictors were combined into a risk index, which was further tested and compared by ROC curve analysis. Results: Post-operative infection was associated with a significantly higher mortality (50.7% vs. 33.3%). Total leucocyte count, total bilirubin, early biliary complications, fever and C-reactive protein were found to be independent predictors of early infectious complications after LDLT. The risk index predicted infection with the highest sensitivity and specificity as compared with each predictor on its own (AUC = 0.91, 95% CI: 0.830-0.955, p < 0.0001). Conclusions: The use of a combined risk index for early diagnosis of post-operative infections can efficiently identify high risk patients.
Gastroenterology, 1999
Liver transplantation for hepatitis C virus (HCV)-related liver disease is characterized by frequent graft infection by HCV. The prognosis and risk factors for morbidity and mortality in this condition were determined. A retrospective study of 652 consecutive anti-HCV-positive patients undergoing liver transplantation between 1984 and 1995 in 15 European centers was conducted; 102 patients coinfected with hepatitis B virus (HBV) received immunoglobulin prophylaxis for antibody to hepatitis B surface antigen. Overall, 5-year survival was 72%. Five-year actuarial rates of hepatitis and cirrhosis were 80% and 10%. Genotypes 1b, 1a, and 2 were detected in 214 (80%), 24 (9%), and 24 (9%) of 268 patients analyzed. The only discriminant factor for patient or graft survival was hepatocellular carcinoma as primary indication. Independent risk factors for recurrent hepatitis included the absence of HBV coinfection before transplantation (relative risk [RR], 1.7; 95% confidence interval [CI], 1.2-2.6; P = 0.005), genotype 1b (RR, 2; 95% CI, 1.3-2.9; P = 0.01), and age &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 49 years (RR, 1.4; 95% CI, 1.1-1.8; P = 0.01). The results of transplantation for HCV-related disease are compromised by a significant risk of cirrhosis, although 5-year survival is satisfactory. Genotype 1b, age, and absence of pretransplantation coinfection by HBV are risk factors for recurrent HCV.
Predictors of patient and graft survival following liver transplantation for hepatitis C
Hepatology, 1998
Diseases Liver Transplantation Database to determine whether pretransplantation patient or donor variables could identify a subset of HCV-infected recipients with poor patient survival. Between April 15, 1990, and June 30, 1994, 166 HCV-infected and 509 HCV-negative patients underwent liver transplantation at the participating institutions. Median follow-up was 5.0 years for HCV-infected and 5.2 years for HCV-negative recipients. Pretransplantation donor and recipient characteristics, and patient and graft survival, were prospectively collected and compared. Cumulative patient survival for HCV-infected recipients was similar to that of recipients transplanted for chronic non-B-C hepatitis, or alcoholic and metabolic liver disease, better than that of patients transplanted for malignancy or hepatitis B (P ؍ .02 and P ؍ .003, respectively), and significantly worse than that of patients transplanted for cholestatic liver disease (P ؍ .001). Recipients who had a pretransplantation HCV-RNA titer of H1 ؋ 10 6 vEq/mL had a cumulative 5-year survival of 57% versus 84% for those with HCV-RNA titers of F1 ؋ 10 6 vEq/mL (P ؍ .0001). Patient and graft survival did not vary with recipient gender, HCV genotype, or induction immunosuppression regimen among the HCV-infected recipients. While longterm patient and graft survival following liver transplantation for end-stage liver disease secondary to HCV are generally comparable with that of most other indications, higher pretransplantation HCV-RNA titers are strongly associated with poor survival among HCV-infected recipients. (HEPATOLOGY 1998;28:823-830.)
Comparative Analysis of Outcome Following Liver Transplantation in US Veterans
American Journal of Transplantation, 2004
The purpose of this study was to evaluate whether there was a difference in mortality following orthotopic liver transplantation (OLT) in a US veteran (VA) population (n = = 149) compared to a non-VA (university) population (n = = 285) and what factors could explain this difference. Survival following OLT for 149 VA patients was compared with that of 285 university patients. By Kaplan-Meier survival analysis, VA patients had higher mortality than university patients with respective 1-year, 3-year, and 5-year survival of 82%, 75%, and 68% vs. 87%, 82%, and 78% (p = = 0.006). Gender, etiology of end-stage liver disease (ESLD) and donor age (i.e. older than 34 years) also significantly influenced survival. However, when donor and recipient age, gender, model for end-stage liver disease (MELD) score, and etiology of liver disease were included with hospital status in a multivariate Cox proportional hazards model, the VA population did not have higher mortality. A final model to predict mortality following transplantation was derived for all 434 patients where individuals were assigned risk scores based on the equation R = = 0.219 (gender) + + 0.018 (donor age) + + 0.032 (recipient age) + + 0.021 (MELD), where recipient age, donor age, and MELD score are the respective continuous variables and gender = = 1 (men) and 0 for women (c-statistic = = 0.71).
Risk Factors for Early Mortality in Liver Transplant Patients
Transplantation Proceedings, 2018
Background. Liver transplantation (LT) is an established treatment for patients with end-stage liver disease. The significant advances in surgical technique, immunosuppression therapy, and anesthesiological management have dramatically improved short-and longterm outcomes. The aim of this study is to correlate specific surgical and anesthesiological variables with causes of early death in LT recipients. Methods. A retrospective observational analysis of adult patients who underwent LT in the period 2012 to 2016 and died within 90 days following LT was conducted. Exclusion criteria were intraoperative death, split liver, and domino transplant. Death was considered a dependent variable and classified into 3 different groups: death by sepsis, vascular events not related to the graft, and primary non-function. Donor and recipient variables were considered and analyzed using Fisher's exact test. Results. Statistically significative associations (P value < .05) were found between renal function support, retransplantation, and the number of fresh frozen plasma units transfused in one group and early death due to sepsis in the other. Conclusions. This study identified some risk factors associated with the specific cause of early death in liver transplantation. The clinical implications of these findings are the ability to stratify patients at high risk of early death by planning more intensive and accurate management for them. A DVANCES in the perioperative management of liver transplantation (LT) patients have improved outcomes, reflected in decreased short-and long-term morbidity and mortality. However, the tendency to transplant very sick recipients explains why the morbidity rate is unchanged in the early post-transplant period and often results in patient death. Different studies have been conducted to define factors influencing early mortality but none have defined the correlation between these factors and cause of death. The aim of this study is to define variables leading to a known cause of early death in the posttransplant period. MATERIALS AND METHODS A retrospective analysis of a prospective database of LT performed between January 2012 and January 2016 at the Hepatobiliary Surgery and Liver Transplantation Unit of Padua University Hospital was conducted. Selection criteria for the study included adult liver transplant recipients who died within 3 months due to the procedure. Cause of death was categorized into 3 groups: sepsis, vascular events not related to the graft, and primary non-function (PNF). Sepsis was defined using the criteria of the Third International Consensus Task Force [1]: vascular events were described as vascular complications not related with the graft and PNF was defined as aspartate aminotransferase level 3000 associated with at least one of the following: international normalized ratio 2.5, acidosis corresponding to arterial pH 7.30 or venous pH 7.25, and/or serum lactate levels 4 mM. For patients who needed a retransplantation (Re-LT), variables were collected from the last transplant. Exclusion criteria were intraoperative death, domino transplant, and patients who received a split graft.
Effect of Kidney Transplantation on Outcomes among patients with Hepatitis C
Journal of the …, 2011
The long-term outcome of kidney transplantation in patients infected with hepatitis C virus (HCV) and end stage renal disease (ESRD) is not well described. We retrospectively identified 230 HCV-infected patients using enzyme immunoassay and nucleic acid testing obtained during the transplant evaluation. Of 207 patients who had a liver biopsy before transplant, 44 underwent 51 follow-up liver biopsies at approximately 5-year intervals either while on the waitlist for a kidney or after kidney transplantation. Advanced fibrosis was present in 10% of patients biopsied, identifying a population that may warrant consideration for combined liver-kidney transplantation. Kidney transplantation does not seem to accelerate liver injury; 77% of kidney recipients who underwent follow-up biopsies showed stable or improved liver histology. There was a higher risk for death during the first 6 months after transplant, but undergoing transplantation conferred a long-term survival advantage over remaining on the waitlist, which was evident by 6 months after transplant (HR, 0.32; 95% CI, 0.17 to 0.62). Furthermore, the risk for death resulting from infection was significantly higher during the first 6 months after transplant (HR, 26.6; 95% CI, 5.01 to 141.3), whereas there was an early (Յ6 months) and sustained decrease in the risk for cardiovascular death (HR, 0.20; 95% CI, 0.08 to 0.47). In summary, these data suggest the importance of liver biopsy before transplant and show that kidney transplantation confers a long-term survival benefit among HCV-infected patients with ESRD compared with remaining on the waitlist. Nevertheless, the higher incidence of early infection-related deaths after transplant calls for further study to determine the optimal immunosuppressive protocol.
Worse Outcomes Associated With Liver Transplants: An Increasing Trend
Cureus, 2021
Background and aim Since individuals in the early stages of liver cirrhosis are typically asymptomatic, the prevalence of liver cirrhosis may be underestimated. Liver cirrhosis has a significant morbidity and mortality rate, with 1.03 million deaths worldwide each year. For end-stage liver disease, liver transplantation is a potential therapeutic option. The goal of our research was to examine the current trend in liver transplants using data from a national database. Methods Using the International Classification of Diseases (ICD)-9 codes, we identified individuals who had a liver transplant during the index hospital admission in the Nationwide Inpatient Sample from 2007 to 2011. This national sample of patients is from the United States. We looked at the yearly trend in liver transplants and related outcomes, such as duration of hospitalization (DOH), hospital expenses, and mortality in the hospital. In order to find determinants of mortality, we used a multivariate analysis. Results There were 25,331 patients hospitalized (weighted for national estimate). Between 2007 and 2011, the number of transplants grew by 1.2%. The majority of transplant recipients were Caucasian (57%), with an average age of 54 years, had a private healthcare plan (53%), and had average earnings in the upper quartile by zip code (26%). Patients with a higher Charlson Comorbidity Index (79% had a score of four) were more likely to be admitted to a southern hospital (33%), an academic hospital (>99%), and a large capacity hospital (90%). Seventy percent of liver transplant recipients received cadaver donors. Hepatitis C was the most prevalent reason for transplant (30%), followed by hepatocellular carcinoma (HCC) (29%) and alcoholic liver disease (25%). In 2011, compared to 2007, there was an upward rise in fatality (from 3.8% to 5.1%), average hospital expenditures (from 335,504to335,504 to 335,504to498,369), and DOH (from 17.4 to 22.7 days). The cost of hospitalization was two billion dollars per year. The independent variables related to an increased mortality on multivariate analysis were African American race (OR: 2.