PROPENSITY SCORE MATCHED RISK OF BILIARY COMPLICATIONS AFTER LIVER TRANSPLANT AND OUTCOME BY DONOR TYPE

Abstract

Background: Donation after circulatory death (DCD), donation after brain death (DBD), and living donor (LD) liver transplantation (LT) are three types of donors used in patients with end-stage liver diseases. Each type has unique benefits, risks, and potential complications. In this study, we assess the risk of biliary complications, and their effect on long-term outcome. Methods: We collected data on all consecutive DCD, DBD and LD-LT recipients between 1989 and 2019 from a single center, and used propensity score matching to identify three groups. Patient survival, graft survival, and biliary complications (bile leak, anastomotic (AS) and non-anastomotic strictures (NAS)) were analyzed and compared between groups. Adjusted p-values were calculated using multivariate Cox regression models. Results: We identified 141 DCDs, 3,226 DBD, and 386 LD-LT in our cohort, with significantly different recipient age, gender, etiology of liver disease, Na-Model for End-Stage Liver Disease (MELD), incidence of hepatocellular carcinoma (HCC), and donor age, gender, and cold ischemic time. Propensity score matching allowed correction for all differences except MELD, presence of HCC, and etiology of liver disease. This produced three groups of 138 recipients each. Adjustment for MELD, HCC, and etiology of liver disease was then performed using Cox models. Eighteen LT recipients (4.3%) had arterial complications (thrombosis and stenosis; no difference between groups). Bile leak was identified in 10.1% of DCD-LTs, versus 7.2% of DBD-LTs, and 36.2% of LD-LTs (p-values=0.240 and <0.001, respectively). Anastomotic biliary stricture developed in 28.3% DCD-LTs, versus 18.1% of DBD-LTs, and 43.5% of LD-LTs (p-values=0.038 and 0.006, respectively). Non-anastomotic biliary stricture was present in 15.2% of DCD-LT s, versus 1.4% of DBDs-LT, and 4.3% of LD-LTs (p-values=0.004 and 0.005, respectively). Eighteen patients (4.3%) were retransplanted and there was no significant difference in retransplant rate between groups. LD-LTs free of any biliary complications had the best patient survival whereas DCD-LTs with ≥1 biliary complication (presence of a bile leak and/or AS and/or NAS) had the worst survival (Figure). Among the 21 DCD-LT patients with non-anastomotic strictures, six died, two were retransplanted, three remain stent dependent, and ten were ultimately stent-free. Conclusion: DCD and LD-LT recipients had significantly higher rates of biliary complications. Biliary complications in DCD-LTs had the most significant impact on survival, although two thirds of the recipients with ischemic cholangiopathy could ultimately achieve a favorable outcome.