List For Orthotopic Liver Transplantation Research Articles

Limited tumour progression beyond Milan criteria while on the waiting list does not result in unacceptable impairment of survival

Defining optimum management of patients progressing beyond Milan criteria on the waiting list is a controversial topic. Our aim was to determine whether the policy of allowing a limited progression beyond enlistment criteria permits acceptable post-transplant outcomes in terms of survival and recurrence. Patients with hepatocellular carcinoma included on the waiting list for orthotopic liver transplantation (OLT) between January 1989 and December 2016 were analysed. Tumour features were assessed at inclusion on the waiting list, before OLT and at explant pathology. Patients were retained on the waiting list despite exceeding enlistment criteria if not presenting with macrovascular invasion, extrahepatic spread or cancer-related symptoms. A total of 495 patients constituted the target population. Comparison between the Milan-in (n= 434) and Milan-out (n= 61) groups showed statistically significant differences in: largest tumour size; BCLC stage; patients treated before OLT; alpha-fetoprotein, and time on the waiting list. Milan-out patients showed a significantly higher number of poorly differentiated nodules, satellitosis and microscopic vascular invasion. The 1-, 3-, 5- and 10-year survival rate was 89.6%, 82.5%, 75%, and 55.5%, vs. 83.6%, 70.5%, 65.5%, and 53.9% for Milan-in/Milan-out patients, respectively. Recurrence rates at 1, 3, 5 and 10 years were 1.2%, 3.3%, 5.5%, and 10.8% vs. 7.1% 14.5%, 23%, and 23% for Milan-in and Milan-out patients, respectively (p <0.01). This study shows that although limited tumour progression without reaching major adverse predictors (vascular invasion, extrahepatic spread, cancer symptoms) has an expected impact on recurrence rate, overall survival remains above the minimum proposed benchmark of 65% at 5 years. The clinically relevant increase in tumour recurrence must be considered when analysing the benefit of this approach in the face of limited organ supply. When considering orthotopic liver transplantation for patients with hepatocellular carcinoma, optimum results are achieved when transplanting patients within the Milan criteria. However, the most appropriate strategy for patients who progress beyond these criteria while on the waiting list is still unclear. Herein, we show that transplantation is associated with acceptable overall survival in select patients who progress beyond the Milan criteria, although recurrence rates were notably higher. Therefore, the assessment of transplantation viability in these patients must consider the availability of organs and the impact on other patient categories.

The von Willebrand Factor Facilitates Model for End-Stage Liver Disease-Independent Risk Stratification on the Waiting List for Liver Transplantation.

Background and AimsThe Model for End‐Stage Liver Disease (MELD) is used for clinical decision‐making and organ allocation for orthotopic liver transplantation (OLT) and was previously upgraded through inclusion of serum sodium (Na) concentrations (MELD‐Na). However, MELD‐Na may underestimate complications arising from portal hypertension or infection. The von Willebrand factor (vWF) antigen (vWF‐Ag) correlates with portal pressure and seems capable of predicting complications in patients with cirrhosis. Accordingly, this study aimed to evaluate vWF‐Ag as an adjunct surrogate marker for risk stratification on the waiting list for OLT.Approach and ResultsHence, WF‐Ag at time of listing was assessed in patients listed for OLT. Clinical characteristics, MELD‐Na, and mortality on the waiting list were recorded. Prediction of 3‐month waiting‐list survival was assessed by receiver operating characteristics and net reclassification improvement. Interestingly, patients dying within 3 months on the waiting list displayed elevated levels of vWF‐Ag (P < 0.001). MELD‐Na and vWF‐Ag were comparable and independent in their predictive potential for 3‐month mortality on the waiting list (area under the curve [AUC], vWF‐Ag = 0.739; MELD‐Na = 0.764). Importantly, a vWF‐Ag cutoff at 413% identified patients at risk for death within 3 months of listing with a higher odds ratio (OR) than the previously published cutoff at a MELD‐Na of 20 points (vWF‐Ag, OR = 10.873, 95% confidence interval [CI], 3.160, 36.084; MELD‐Na, OR = 7.594, 95% CI, 2.578, 22.372; P < 0.001, respectively). Ultimately, inclusion of vWF‐Ag into the MELD‐Na equation significantly improved prediction of 3‐month waiting‐list mortality (AUC, MELD‐Na–vWF = 0.804).ConclusionsA single measurement of vWF‐Ag at listing for OLT predicts early mortality. Combining vWF‐Ag levels with MELD‐Na improves risk stratification and may help to prioritize organ allocation to decrease waiting‐list mortality.

The possibilities of interventional radiology before and after orthotopic liver transplantation

Presented the case of a combined approach preparation of 47 years old patient with primary biliary cirrhosis for orthotopic liver transplantation (OLT) and arterial flow insufficiency correction after surgery. The patient was under waiting list for OLT due liver cirrhosis progression. The patient underwent Intraportal infusion of autologous bone marrow mononuclear cells (MNC) which is allowed temporary stabilized the cirrhotic transformation. The transjugular intrahepatic portosystemic shunt (TIPS) procedure performed due to portal hypertension progression with episodes of bleeding from the esophageal and gastric varices, that allowed to receive organ donor and OLT. At 6 months after OLT the patient had clinical signs of a jaundice caused by splenic artery steal syndrome which was corrected by endovascular intervention: splenic artery trunk embolization.

Hepatic encephalopathy before and neurological complications after liver transplantation have no impact on the employment status 1 year after transplantation.

AIMTo investigate the impact of hepatic encephalopathy before orthotopic liver transplantation (OLT) and neurological complications after OLT on employment after OLT.METHODSOne hundred and fourteen patients with chronic liver disease aged 18-60 years underwent neurological examination to identify neurological complications, neuropsychological tests comprising the PSE-Syndrome-Test yielding the psychometric hepatic encephalopathy score, the critical flicker frequency and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), completed a questionnaire concerning their occupation and filled in the short form 36 (SF-36) to assess health-related quality of life before OLT and 12 mo after OLT, if possible. Sixty-eight (59.6%) patients were recruited before OLT, while on the waiting list for OLT at Hannover Medical School [age: 48.7 ± 10.2 years, 45 (66.2%) male], and 46 (40.4%) patients were included directly after OLT.RESULTSBefore OLT 43.0% of the patients were employed. The patients not employed before OLT were more often non-academics (employed: Academic/non-academic 16 (34.0%)/31 vs not employed 10 (17.6%)/52, P = 0.04), had more frequently a history of hepatic encephalopathy (HE) (yes/no; employed 15 (30.6%)/34 vs not employed 32 (49.2%)/33, P = 0.05) and achieved worse results in psychometric tests (RBANS sum score mean ± SD employed 472.1 ± 44.5 vs not employed 443.1 ± 56.7, P = 0.04) than those employed. Ten patients (18.2%), who were not employed before OLT, resumed work afterwards. The patients employed after OLT were younger [age median (range, min-max) employed 47 (42, 18-60) vs not employed 50 (31, 29-60), P = 0.01], achieved better results in the psychometric tests (RBANS sum score mean ± SD employed 490.7 ± 48.2 vs not employed 461.0 ± 54.5, P = 0.02) and had a higher health-related quality of life (SF 36 sum score mean ± SD employed 627.0 ± 138.1 vs not employed 433.7 ± 160.8; P < 0.001) compared to patients not employed after OLT. Employment before OLT (P < 0.001), age (P < 0.01) and SF-36 sum score 12 mo after OLT (P < 0.01) but not HE before OLT or neurological complications after OLT were independent predictors of the employment status after OLT.CONCLUSIONHE before and neurological complications after OLT have no impact on the employment status 12 mo after OLT. Instead younger age and employment before OLT predict employment one year after OLT.

Health-related quality of life and affective status in liver transplant recipients and patients on the waiting list with low MELD scores

BackgroundThis study seeks to examine the impact of orthotopic liver transplantation (OLT) on Health-Related Quality of Life (HRQoL) and mental health in patients with different MELD scores. MethodsPatients who has undergone orthotopic liver transplant (OLT) or were on the waiting list for OLT were submitted to HRQoL and depression/anxiety assessment by questionnaire: Short-Form 36 (SF-36), Questions on Life Satisfaction (FLZ-M), Patient Health Questionnaire-4 (PHQ-4). Data were analysed following division of patients into three groups: pretransplant patients with a MELD score <10, ≥10, and OLT recipients. ResultsThe surveys were sent to 940 consecutive patients within one week in June 2013. Of these 940 patients, 869 (92.4%) met the inclusion criteria. In total, 291 (33.5%) eligible questionnaires (OLT group: 235, MELD <10: 25; MELD _10: 31) were suitable for analysis. General health (GH), vitality (VIT), and mental health (MH) were lower in both pretransplant groups compared to the OLT group (all p < 0.05). Anxiety and depression were higher in the MELD <10 group than in the OLT group (anxiety: p < 0.05; depression: p < 0.01). DiscussionPatients with low MELD scores seem to benefit from OLT with regards to HRQoL and mental health.

Reappraisal of prognostic value of MELD-Na score: A new tool for liver transplant prioritization in HCV-infected patients

Introduction: The classical Model for End-Stage Liver Disease (MELD) can still be considered as the most reliable tool to allocate patients on waiting list for orthotopic liver transplantation (OLT). Nevertheless, the introduction of sodium in the model has partly improved its performance, but this result requires further confirmation.

New-onset cognitive dysfunction impairs the quality of life in patients after liver transplantation

Patients after orthotopic liver transplantation (OLT) may show cognitive dysfunction. To date, it has not been clear whether this dysfunction is due to residual hepatic encephalopathy (HE) or new-onset cognitive disturbances. Just as little is known about the course and clinical significance. In this prospective, observational study, 50 patients on the waiting list for OLT were examined in an outpatient setting before OLT and 6 and 12 months after OLT with the Psychometric Hepatic Encephalopathy Score, the Inhibitory Control Test, and the critical flicker frequency for the diagnosis of HE; in addition, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was used as a tool for the measurement of global cognitive function. The Short Form 36 health survey was used to assess health-related quality of life. Twelve months after OLT, cognitive dysfunction characteristic of HE had resolved, but a secondary cognitive decline became apparent and had features different from those known with HE. Approximately 70% of the patients deteriorated in at least 1 cognitive domain of RBANS. This cognitive decline was related to neither a history of HE nor a history of alcohol abuse, but it was accompanied by a decline in the quality of life. In conclusion, OLT improves HE but is frequently followed by new-onset cognitive dysfunction, which can interfere with the quality of life.

Orthotopic Liver Transplantation in Critically Ill Cirrhotic Patients With Multi-Organ Failure: A Single-Center Experience

Due to the lack of donor organs for orthotopic liver transplantation (OLT) in Germany, a larger proportion of patients advance to multi-organ failure (MOF) before OLT. Twenty-three patients on the waiting list for OLT were admitted to our intensive care unit (ICU) from January 2007 until September 2009. They consisted of 16 men and 7 women of median (25th–75th percentile) age of 60 years (54–65). Acute Physiology and Chronic Health Evaluation (APACHE II) score upon ICU admission was 26 (19–34); Model of End-Stage Liver Disease (MELD) score was 29 (22–41); Sequential Organ Failure Assessment (SOFA) score was 12 (8–16). The 90-day mortality rate was 39%. A decrease in MELD score during the first 48 hours (−2 [−5–0] vs 2 [−1–4]; P = .019) was associated with survival. Thirteen patients underwent transplantation from the ICU. By the time of the OLT, the MELD scores had deteriorated to 38 (33–39) and SOFA scores to 19 (18–19). All patients were mechanically ventilated and received hemodynamic support with catecholamines. Ten of 13 patients (77%) received renal replacement therapy and/or single pass albumin dialysis. Eight of 13 patients (62%) had a SOFA score of 3 or 4 (organ failure) in each of the respective subscores for the cardiovascular, renal, and respiratory systems at the time of OLT. The 90-day mortality rate after OLT was 38% and the 1-year-mortality rate was 54%. Patients who did not survive 90 days post OLT showed lower MELD scores on admission (33 [18–35] vs 44 [32–46]; P = .045), an increased MELD during the first 48 hours (3 [1–4] vs −2 [−8–1]; P = .002), and a longer ICU stay before OLT (32 [18–37] vs 8 [2–15]; P = .006). In conclusion, OLT may be successful treatment for cirrhotic patients with MOF. Outcomes of MOF in cirrhotic patients may improve after OLT but are generally worse than acceptable. A shorter ICU waiting time seemed to be beneficial.

Beyond Milan criteria – chances and risks of expanding transplantation criteria for HCC patients with liver cirrhosis

Orthotopic liver transplantation (OLT) is, apart from resection, one important curative treatment for hepatocellular carcinoma (HCC) in liver cirrhosis, and especially attractive because it eliminates both the tumor and the underlying liver disease. The application of restrictive inclusion criteria for OLT in HCC patients resulted in favorable long-term recurrence-free survival. These criteria, however, exclude a subgroup of patients which, despite advanced tumor size, demonstrate an acceptable outcome. As a consequence, expansion of the strict Milan criteria has been discussed. However, this will also deteriorate the average outcome of OLT in HCC patients. Considering that we run short of donor organs, more sophisticated prediction models for survival after OLT for HCC patients are needed to identify patients who benefit best from OLT. Neoadjuvant treatment that is frequently applied as a bridging technique for patients on the waiting list for OLT could provide useful information on tumor behavior to better predict the risk of post-OLT tumor recurrence. This might also allow expansion of the Milan criteria to patients with good response to downstaging methods without negatively affecting post-OLT survival. Furthermore, alternative scoring systems have been suggested to identify HCC patients that might still benefit from resection instead of OLT, and molecular tools are being explored to provide predictive information on HCC biology. This review discusses the advantages and risks of extended inclusion criteria for OLT and the currently available data on alternative prediction models and bridging methods in HCC patients.

Model for End-Stage Liver Disease (MELD) Score and Organ Allocation From Cadaveric Donors for 198 Liver Transplantation Procedures Performed in a Single Center

Since February 2002, the United Network for Organ Sharing (UNOS) proposed to adopt a modified version of the Model for End-Stage Liver Disease (MELD) to assign priority on the waiting list for orthotopic liver transplantation (OLT). In this study, we evaluated the impact of MELD score on liver allocation in a single center series of 198 liver recipients (mean age of patients, 52.21 ± 8.92 years), considering the relationship between clinical urgency derived from MELD score (overall MELD, 18.7 ± 6.83; MELD <15 in 69 patients, MELD ≥15 in 129 patients) and geographical distribution of cadaveric donors (inside/outside Liguria Region, 125/73). The waiting time for OLT was 230 ± 248 days, whereas the 3-month and 1-year patient survivals were 87.37% and 79.79%, respectively. No difference was observed for MELD score retrospectively calculated for patients who underwent OLT before February 2002 (n = 71) compared with MELD score calculated for patients who received a liver thereafter (18.26 ± 6.68 vs 18.94 ± 6.92; P = .504). No significant difference was found in waiting time before and after adoption of MELD score (213 ± 183 vs 238 ± 278 days; P = .500), or by stratifying patients for MELD <15/≥15 (225 ± 234 vs 232 ± 256 days; P = .851). Using the geographical distribution of donors as a grouping variable (outside vs inside Liguria Region), no significance occurred for MELD score (19.68 ± 7.42 vs 18.17 ± 6.42; P = .135) or waiting time (211 ± 226 vs 242 ± 261 days; P = .394). In our series, more OLTs were performed among sicker patients and no differences were found in the management of livers procured from cadaveric donors outside or inside Liguria Region. However, further efforts are needed to reduce the waiting time among patients with higher MELD scores.

Model for End-Stage Liver Disease (MELD) Score System to Evaluate Patients With Viral Hepatitis on the Waiting List: Better Than the Child-Turcotte-Pugh (CTP) System?

Background The Model for End-Stage Liver Disease (MELD), based on creatinine, bilirubin, and International normalized ratio (INR), has been shown to be superior to the Child-Turcotte-Pugh (CTP) score in predicting 3-month mortality among patients on the transplant waiting list due to end-stage liver disease (ESLD). An additional advantage of MELD is the possibility to add “adjustment points” for exceptional patients at risk for death because of liver disease not identified by changes in the used parameters, as occurs in the case of hepatocellular carcinoma (HCC). Although it is useful, MELD has some important limitations: There are no differences for patients with or without ascites, and for the absence of other laboratory parameters involved in the etiology of disease. In this study, we evaluated dropouts of patients on the waiting list for orthotopic liver transplantation (OLT) based upon the characteristics of these subjects before and after introduction of the MELD score. Methods All patients on the OLT waiting list from June 1, 2006 to June 30, 2007 were enrolled in the MELD group (A) and evaluated with CHILD and MELD score, while those listed from January 1, 2004 to May 31, 2005 were enrolled in pre-MELD group (B) to be evaluated with CHILD. In these subjects we assessed the drop out frequency and waiting time and we compared the results to assess possible differences (U Mann-Whitney Test; P <.05). Results The total number of patients included in this study was 176: 116 patients in Group A and 60 in Group B. We had a drop-out frequency of 21% with a median of 9 ± 6 S.E. months in Group A, while 9% with a median of 15 ± 8 months S.E. in Group B. The dropout frequencies were as follows: Group A - 16 deaths (1 HCC - 15 disease complications) while in Group B we had 13 drop outs, 10 exitus (4 HCC and 6 disease complications) and three exclusions for nonmedical reasons. In Group A we had a higher number of deaths due to disease complications than in group B ( P <.05). Further, we had 32 OLTx in Group A and 45 in Group B. Survival rate did not show any differences between the two groups while number needed to harm was 11. Conclusions The use of MELD score in this group of patients produced an advantage for HCC, but seemed to cutoff patients with viral hepatitis complications during the waiting time. Particularly, about one in every 11 patients may receive an harm using this score system. Other parameters should be introduced as adjustment points to make the MELD score suitable also for patients with infectious liver diseases.

Transcatheter Arterial Chemoembolization in Patients with Hepatocellular Carcinoma on the Waiting List for Orthotopic Liver Transplantation

The objective of this study was to perform a retrospective analysis of patients with hepatocellular carcinoma (HCC) who underwent transcatheter arterial chemoembolization (TACE) before undergoing liver transplantation at our institution. From January 2000 to August 2005, 56 patients with HCC underwent TACE before orthotopic liver transplantation (OLT). Radiologic findings before and after TACE were assessed and correlated with histologic findings after OLT. The area of induced necrosis was pathologically evaluated in each HCC nodule. One hundred thirty-one HCC nodules were detected at histologic study. One hundred seventeen HCC nodules (91.4%) were hyperenhancing in the arterial phase on the preoperative imaging studies. The percentage of tumor necrosis was greater than 90% in 48 nodules (38%), between 50% and 90% in 19 nodules (15%), and less than 50% in 61 nodules (48%); tumor necrosis data were not recorded for the remaining three nodules. The size of the preoperatively detected lesions ranged from 0.2 to 9 cm (mean, 2.58 cm). The mean percentage of tumor necrosis was 67.8% in this group, but it rose to 79.2% in the hypervascular lesions. The size of the nodules that were not detected preoperatively ranged from 0.1 to 1.9 cm (mean, 0.68 cm), and the mean percentage of tumor necrosis was only 1.57%. TACE is a safe treatment in well-selected patients. Its antitumoral effect is high in hypervascular lesions (mean necrosis, 79.2%). It provides good local control in preoperatively diagnosed HCC (mean necrosis, 67.8%), but its impact is limited in lesions not detected preoperatively (mean necrosis, 1.57%).

Therapy Insight: hepatopulmonary syndrome and orthotopic liver transplantation

Hepatopulmonary syndrome (HPS)--a pulmonary complication observed in patients who have chronic liver disease and/or portal hypertension--is attributed to intrapulmonary vascular dilatation and induces severe hypoxemia. HPS is mainly detected when patients are included on the waiting list for orthotopic liver transplantation (OLT) and can be diagnosed by blood gas analysis, transthoracic contrast-enhanced echocardiography or body scan with (99m)Tc-labeled macroaggregated albumin perfusion. When the partial pressure of arterial oxygen (PaO(2)) is >or=80 mmHg, it is unlikely that the patient has HPS. When the PaO(2) is <80 mmHg, imaging techniques should be used to confirm or exclude pulmonary vascular dilatation. When a diagnosis of HPS is confirmed, knowing the degree of hypoxemia is crucial for optimum patient management. Patients who have a PaO(2) >or=50 mmHg but <60 mmHg should be prioritized for OLT. This procedure is not indicated for patients with a PaO(2) between 60 mmHg and 80 mmHg, although follow-up every 3 months is recommended to detect any deterioration of the PaO(2). A PaO(2) of <50 mmHg might preclude OLT, because mortality and morbidity after OLT are greatly increased in these patients.

Diagnostik des hepatozellulären Karzinoms

Risk factors and symptoms of hepatocellular carcinoma (HCC): The main risk factors of HCC include infection with hepatitis B or C virus, as well as alcohol consumption. There are no specific symptoms of HCC, making early diagnosis and detection of the disease difficult. When HCC presents with specific clinical symptoms, the tumour is typically very far advanced. Surveillance in liver cirrhosis: The most common serological marker used in HCC diagnosis is alpha-fetoprotein (AFP), but other tumour markers such as the des-gamma-carboxyprothrombin (DGCP) or fractions of AFP (AFP-L3) exist and there use is discussed in this context. Surveillance should be done by sonography at 6 (to 12) months intervals. The single nodule in the cirrhotic liver: Ultrasound is the most commonly used imaging modality for detecting HCC tumour nodules with a large range of reported sensitivities. HCC may appear as a hypoechoic, isoechoic, or hyperechoic round or oval lesion with intratumoural flow signals on Doppler or power Doppler sonography. The differentiation of smaller malignant lesions in cirrhotic livers can be improved by contrast-enhanced ultrasound (CEUS). Spiral computed tomography (CT) and magnetic resonance imaging (MRI) with and without contrast enhancement play an important role in the diagnosis and staging of HCC. If the vascular pattern on imaging is not typical, biopsy becomes necessary. The patient with known HCC: Different tumour markers are used in the evaluation of tumour progression, prediction of patient outcome and treatment efficacy. Among the various staging systems used in the context of HCC, the Barcelona-Clinic-Liver-Cancer (BCLC) staging system is currently the only staging system that takes into account tumour stage, liver function, physical status and cancer-related symptoms. Beside surgical resection, non-surgical treatments such as percutaneous ethanol injection (PEI), radiofrequency thermoablation (RFTA) and trans-arterial chemoembolisation (TACE) are used. Successful tumour "bridging" with ablative therapy methods can be achieved in carefully selected patients on the waiting list for orthotopic liver transplantation. Contrast-enhanced sonography is able to control the ablation treatment of HCC.

Primary Sclerosing Cholangitis Is a More Common Indication for Orthotopic Liver Transplantation among African American Than Non-African American Patients

Purpose: Primary sclerosing cholangitis (PSC) is a progressive, incurable condition of unknown etiology, characterized by inflammation, fibrosis, destruction and loss of interlobular-sized bile ducts, leading to biliary cirrhosis and liver failure. Orthotopic liver transplantation (OLT) is the only life-extending intervention for patients with end-stage PSC. Recent US Scientific Registry of Transplant Recipients (SRTR) data indicate that among patients with PSC being added to the United Network for Organ Sharing (UNOS) waiting list the proportion of African Americans (AA) was greater than non-AAs, compared to other disease indications. This suggests that PSC may run a more aggressive clinical course. It was our aim to determine whether the proportion of AA patients with PSC undergoing OLT per unit time was different from the proportion of non-AA patients undergoing OLT for PSC. Methods: The SRTR was reviewed between 1998 and 2002 inclusive for all adults (18 – 80 years) who were added to the UNOS waiting list for OLT. The proportions of AA and non-AA patients undergoing OLT for PSC within 1 year, 1–2 years, 2–3 years, and > 3 years of being added to the waiting list were calculated, and compared using the Chi-square test. Results: From 1998 to 2002 inclusive 39,878 patients were added to the UNOS waiting list for OLT. 2173 (5.45%) had PSC. Of these, 262 (12.1%) were AA. The proportions of AA patients with PSC who underwent OLT within 1 year, 1–2 years, 2–3 years, and >3 years of being added to the waiting list were: 28.2% (74/262), 13.7% (36/262), 8.8% (23/262) and 5.7% (15/262). 114/262 (43.5%) AA patients with PSC did not undergo OLT during the study period. The proportions of non-AA patients with PSC who underwent OLT within 1 year, 1–2 years, 2–3 years, and > 3 years of being added to the waiting list were: 33.5% (640/1911), 11.5% (220/1911), 4.7% (89/1911) and 4.9% (93/1911). 869/1911 (45.5) non-AA patients with PSC did not undergo OLT during this period. Except for the period < 1 year from the time of OLT listing, the proportion of AA patients with PSC undergoing OLT was significantly greater than the porportion of non-AA patients with PSC who underwent OLT (P= 0.026). Conclusion: These outcomes for AA patients with PSC suggest that their disease course may be more agressive, given that patients underwent OLT sooner from the time of listing than did non-AA patients. An alternative explanation is that AA patients with PSC were simply sicker than non-AA patients at the time of listing for OLT.

Selection criteria for liver transplantation in patients with hepatocellular carcinoma: Beyond tumor size and number?

Selection criteria for liver transplantation in patients with hepatocellular carcinoma: Beyond tumor size and number?

Pretransplant screening of sobriety with carbohydrate-deficient transferrin in patients suffering from alcoholic cirrhosis

Abstract Sufficient assessment of potential candidates for orthotopic liver transplantation (OLT) is the most important factor for a low alcohol relapse rate after transplantation in patients suffering from alcoholic cirrhosis. In the current study the efficiency of pretransplant screening with carbohydrate-deficient transferrin (CDT) was analysed in patients on the waiting list for OLT. A prospective study was performed in 44 patients who had undergone OLT for alcoholic cirrhosis. All patients had had pretransplant assessment by a specialist psychologist and were found to have no problems with alcohol. Pre- and post-transplant CDT monitoring was performed. Overall, 790 CDT values were measured in the study population. The median observation period was 2.1 months before and 41.2 months after transplantation, respectively. In 35 patients (80%) pretransplant CDT values were found to be above the reference value, but only one patient suffered an alcohol relapse after transplantation. Of the nine patients (20%) who demonstrated normal CDT before transplantation, two suffered an alcohol relapse after transplantation. CDT is a very useful marker for the monitoring of an alcohol relapse in patients following OLT for alcoholic cirrhosis, as has been previously indicated. However, CDT does not appear to be useful as a pretransplant screening marker for selection of potential transplant candidates suffering from alcoholic cirrhosis.

Pretransplant screening of sobriety with carbohydrate-deficient transferrin in patients suffering from alcoholic cirrhosis

Sufficient assessment of potential candidates for orthotopic liver transplantation (OLT) is the most important factor for a low alcohol relapse rate after transplantation in patients suffering from alcoholic cirrhosis. In the current study the efficiency of pretransplant screening with carbohydrate-deficient transferrin (CDT) was analysed in patients on the waiting list for OLT. A prospective study was performed in 44 patients who had undergone OLT for alcoholic cirrhosis. All patients had had pretransplant assessment by a specialist psychologist and were found to have no problems with alcohol. Pre- and post-transplant CDT monitoring was performed. Overall, 790 CDT values were measured in the study population. The median observation period was 2.1 months before and 41.2 months after transplantation, respectively. In 35 patients (80%) pretransplant CDT values were found to be above the reference value, but only one patient suffered an alcohol relapse after transplantation. Of the nine patients (20%) who demonstrated normal CDT before transplantation, two suffered an alcohol relapse after transplantation. CDT is a very useful marker for the monitoring of an alcohol relapse in patients following OLT for alcoholic cirrhosis, as has been previously indicated. However, CDT does not appear to be useful as a pretransplant screening marker for selection of potential transplant candidates suffering from alcoholic cirrhosis.

IS MELD-SCORE ENOUGH TO PREDICT NOT ONLY DEATH ON WAITING LIST BUT ALTHOUGH POST TRANSPLANT SURVIVAL? CONSIDERATIONS BASED ON 622 PATIENTS.

O163* Aims: Model for End-stage Liver Disease (MELD) score has emerged as a useful tool in predicting mortality in patients awaiting liver transplantation, although it was originally designed to assess short-term prognosis in patients undergoing transjugular intrahepatic portosystemic shunt. Methods: From Jan 1997 to Nov 2003 662 adult patients with End Stage Liver Disease were put on the Waiting List for orthotopic liver transplantation (OLT). 388 patients were transplanted, 131 died on list, 55 were removed from the waiting list due to tumor progression (n=11), poor condition (n=6), non compliance (n=7), clinical improvement (n=28) or technical reasons (n=3). 48 patients are still awaiting OLT. All patients were categorized according to the MELD Score. Results: The difference in the MELD Score at listing versus MELD Score off listing (died on list, transplanted or removed) is shown on table below. Patients died on list showed a significant increase during waiting time as well as a significant higher MELD score at listing compared to patients who were transplanted or removed (p<0,001).FigureTable 1 Multivariate analysis (Cox Model) identified meld score at listing (p=0,002; RR 9,3), ascites (p=0,002; RR=9,7) and encephalopathy (p=0,007; RR=7,2) as independent risk factors for death on the waiting list. Patient survival estimated by Kaplan Meier method was similar at 3, 6 and 12 months after transplantation regardless of the MELD Score. However, patients with a MELD Score >=25 showed a remarkable trend towards a lower survival at 3 years (62% versus 80%, p=0.08). This trend is confirmed in a multivariate analysis evaluating MELD Score as a pre-transplant risk factor for long term survival after OLT (p=0,02; RR=5,6). A further detail of interest in this analysis is the fact that patients with MELD Score < 11 showed a higher risk for death after OLT (89% survival) than on waiting list (98% survival) at three months. Conclusions: Our study demonstrated that MELD Score is a strong predictor for death on the waiting list and should also be considered as a pre-transplant risk factor for long term post-transplant survival.

Liver transplantation for hepatocellular carcinoma: analysis of survival according to the intention-to-treat principle and dropout from the waiting list.

A major obstacle for orthotopic liver transplantation (OLT) as treatment for hepatocellular carcinoma (HCC) is tumor growth resulting in dropout from the waiting list for OLT. There is a paucity of data on survival according to intention-to-treat analysis and the rate of dropout from the waiting list for OLT among patients with HCC. To further evaluate these issues, we analyzed the outcome of 46 consecutive patients with HCC listed for OLT between January 1998 and January 2001. Exclusion criteria for OLT were tumor size greater than 5 cm for one to three lesions or four lesions or greater of any size. Twenty-one patients underwent OLT. There were 11 dropouts because of tumor progression and six deaths, including three deaths after dropout. Kaplan-Meier 1- and 2-year intention-to-treat survival rates were 91.7% and 72.6%, respectively. Monthly dropout rates were 0% from 0 to 3 months, 1.5% from 3 to 6 months, 1.0% from 6 to 9 months, 4.9% from 9 to 12 months, and 5.6% from 12 to 15 months. One dropout occurred beyond 15 months among 4 patients remaining at risk. Cumulative probabilities for dropout at 6, 12, and 24 months were 7.3%, 25.3%, and 43.6%, respectively. Predictors for dropout included two or three tumor nodules or a solitary lesion greater than 3 cm at initial presentation and previous hepatic resection. Our results support recent changes in the scheme of organ allocation aimed at reducing the dropout rate and improving outcome for patients with HCC awaiting OLT.