Liver Transplant Program Research Articles

Identifying independent risk factors for graft loss after primary liver transplantation.

The aim of the study is the identification of independent risk factors for re-transplantation after primary liver transplantation beyond the occurrence of hepatic artery thrombosis. Eight hundred thirty-four adult patients undergoing primary liver transplantation were analyzed. A propensity score was developed using multivariable binary logistic regression with hepatic artery thrombosis as the dependent variable. The logit link function of the propensity score was included into multivariable Cox regression analysis for graft survival to adjust the study population. Graft loss was observed in 134 patients (16.1%). Independent significant risk factors for graft loss were recipient platelet count (p=0.040; HR: 1.002; 95%-CI: 1.000-1.003), preoperative portal vein thrombosis (p=0.032; HR: 1.797; 95%-CI: 1.054-2.925), donor age (p<0.001; HR: 1.026; 95%-CI: 1.012-1.040), percentage of macrovesicular steatosis of the graft (p=0.011; HR: 1.037; 95%-CI: 1.009-1.061), early complications leading to revision surgery (p<0.001; HR: 2.734; 95%-CI: 1.897-3.956), duration of the transplant procedure (p<0.001; HR: 1.005; 95%-CI: 1.003-1.007) as well as transplantation of a split liver graft (p=0.003; HR: 2.637; 95%-CI: 1.420-4.728). The logit of the propensity score did not reach statistical significance in the final multivariable Cox regression model (p=0.111) indicating good adjustment for the occurrence of hepatic artery thrombosis. Liver transplant programs might benefit from regular donor organ biopsies to assess the amount of macrovesicular steatosis. An elevated recipient platelet count can promote reperfusion injury leading to graft loss. A liver graft from an elderly donor should not be split or be transplanted in a recipient with detected portal vein thrombosis.

Transplantation for acute alcoholic hepatitis.

Transplantation for acute alcoholic hepatitis.

Middle Hepatic Vein Bleed During Donor Hepatectomy: Technique for Safe Practice

Safe performance of donor hepatectomy is crucial for sustainability of a living donor liver transplantation (LDLT) program. Middle hepatic vein (MHV) is always encountered during parenchymal transection irrespective of right or left donor hepatectomies. Here we present a safe and effective technique for tackling MHV bleed during LDLT from a single centre experience.

Systematic review with meta-analysis: post-operative complications and mortality risk in liver transplant candidates with obesity.

International guidelines rate class III (morbid) obesity (body mass index [BMI]≥40 kg/m2 ) as a relative contraindication for liver transplantation (LT) requiring further research. Moreover, data on the mortality risk in candidates with a BMI: 30-34.9 and 35-39.9 kg/m2 (class I and class II obesity, respectively) are weak. To compare post-operative complications and mortality risks in all obese candidates vs candidates with a BMI: 18.5-29.9 (normal/overweight) assumed as controls. We searched the Cochrane library, PubMed, Scopus, Web-of-Science and article reference lists, restricted to the English language, and selected cohort studies analysing the following outcomes: all-causes mortality (at 30 days, 1-2-3-5 years), post-operative and cardiopulmonary complications, hospital and intensive care unit (ICU) length of stay. Two reviewers independently extracted the studies data and a third one resolved discrepancies. Twenty-four studies comprising 132 162 patients met the inclusion criteria. As compared to controls, mortality risk was increased at all time-periods (except at 3 years) for a BMI≥40, at 30 days for a BMI: 30-34.9 and in none of the considered time-periods for a BMI: 35-39.9. Post-operative complications were significantly higher for a BMI>30 and 30-34.9. Due to the shortage/absence of data, we evaluated cardiopulmonary complications, hospital and ICU length of stay only in the BMI≥30 category. In these patients, only cardiopulmonary complications were increased as compared to controls. Morbid obesity has an impact on patients' survival after LT. However, since even a BMI>30 increases post-transplant complications, new strategies should be included in the LT programme to favour weight loss in all obese candidates.

Commentaries on health services research

Commentaries on health services research

Ursodeoxycholic Acid Therapy in Patients with Primary Biliary Cholangitis with Limited Liver Transplantation Availability

IntroductionThere is little information on survival rates of patients with primary biliary cholangtis (PBC) in developing countries. This is particularly true in Latin America, where the number of liver transplants performed remains extremely low for patients with advanced liver disease who fulfill criteria for liver transplantation. The goal of this study was to compare survival rate of patients with PBC in developing countries who were treated with ursodeoxycholic acid (UDCA) versus survival of patients who received other treatments (OT) without UDCA, prescribed before the UDCA era. Material and MethodsA retrospective study was performed, including records of 78 patients with PBC in the liver unit in a third level referral hospital in Mexico City. Patients were followed for five years from initial diagnosis until death related to liver disease or to the end of the study. Patients received UDCA (15 mg/kg/per day) (n = 41) or OT (n = 37) before introduction of UDCA in Mexico. ResultsResponse to treatment was higher in the group that received UDCA. In the five years of follow-up, survival rates were significantly higher in the UDCA group than in the OT group. The hazard ratio of death was higher in the OT group vs. UDCA group, HR 8.78 (95% CI, 2.52-30.61); Mayo Risk Score and gender were independently associated with the risk of death. ConclusionsThe study confirms that the use of UDCA in countries with a limited liver transplant program increases survival in comparison to other treatments used before the introduction of UDCA.

Multi-professional team's perception of nurses' competences in liver transplantations.

descriptive study with a qualitative approach. Data were collected through a questionnaire. Participants were 12 professionals of the liver transplantation team of a reference hospital. For result interpretation, the thematic analysis technique was employed. the professionals assessed the competences employed by nurses as proactive, autonomous, creative, humanized, capable of teamwork, decision-making and conflict management. this study made it possible to demonstrate that members of the multi-professional team perceived nurses as professionals capable of coordinating and integrating the skills "knowing, doing, being and co-existing", enabling quality care for candidates and receivers of liver transplants, as well as for their families and/or caregivers in all perioperative phases.

Liver transplant for hepatocellular carcinoma in Qatar: an initial experience

Objective: Liver transplant is the best available option for early unresectable hepatocellular carcinoma (HCC). Liver transplant program in Qatar started by the end of 2011 and has progressed steadily since then, and here we report our initial experience. Methods: From December 2011 till present, 16 patients were transplanted, 8 of whom had HCC diagnosed on magnetic resonance imaging. Milan criteria was used to select the patients. Patients were divided into two groups: HCC versus non-HCC groups. Data were summarized as mean±SD. Survival was calculated using Kaplan–Meir curves, and SPSS was used for analysis. Results: Over the study period, sixteen patients were transplanted with a mean follow-up of 1.5±1.3 years. Twelve patients had HCV infection. Fifteen patients were males with a mean age of 52.6±7.4 years at time of transplant. The average length of stay in the intensive care was 2.1±0.7 days and for hospital stay was 12.5±3.4 days. There was no significant difference in the study groups regarding age, sex, average post-operative stay in intensive care unit and in the hospital and survival. There were no reported cases of vascular or biliary complications in both groups. One-year and overall patient survivals after liver transplant are 93% and 87%, respectively. No reported cases of HCC recurrence after transplant. One patient was lost from each group. Conclusion: Despite the initial small number, outcome of transplants is excellent in terms of patient survival, surgical complications and HCC recurrence compared to the international figures.

Red cell alloimmunization & role of advanced immunohaematological support in liver transplantation.

Background & objectives:Transfusion support forms an integral part of liver transplantation programme. Advanced immunohaematology services are required to deal with complex serological problems that can complicate transfusion therapy in these patients. Here, we report on red cell alloimmunization and presence of alloimmunization in donors and patients undergoing liver transplantation in a tertiary care hospital in north India.Methods:Records of 1433 liver transplants performed from January 2009 to March 2015 were retrieved and reviewed. Antibody screening was performed both for liver donors, and recipients and antibody identification was performed for the screen-positive patients.Results:Of the 1433 liver recipients, 32 (2.3%) developed antibodies. Seventeen patients had one or more alloantibodies, five had autoantibodies with an underlying alloantibody and 10 had only autoantibodies in their plasma. The overall alloimmunization rate was 1.5 per cent with 25 alloantibodies identified in 22 patients. Anti-E was the most common specificity identified.Interpretation & conclusions:The presence of alloantibodies can complicate transfusion therapy in patients undergoing liver transplantation, who are already at a high risk of being heavily transfused owing to the nature of surgery and the haemostatic dysfunction from chronic liver disease. Therefore, screening for irregular red cell alloantibodies combined with a rational blood transfusion policy may be essential for these patients.

Reducing the incidence of hepatic artery thrombosis in pediatric liver transplantation: Effect of microvascular techniques and a customized anticoagulation protocol.

We aimed to assess the incidence of HAT over three eras following implementation of microvascular techniques and a customized anticoagulation protocol in a predominantly cadaveric split liver transplant program. We retrospectively reviewed pediatric liver transplants performed between April 1986 and 2016 and analyzed the incidence HAT over three eras. In E1, 1986-2008, each patient received a standard dose of 5U/kg/h of heparin and coagulation profiles normalized passively. In E2, 2008-2012, microvascular techniques were introduced. In E3, 2012-2016, in addition, a customized anticoagulation protocol was introduced which included replacement of antithrombin 3, protein C and S, and early heparinization. A total of 317 liver transplants were completed during the study period, with a median age of 31.7months. In E1, 22% of grafts were cadaveric in situ split grafts, while the second and third eras used split grafts in 59.0% and 64.9% of cases, respectively. HAT occurred in 9.5% in the first era, 11.5% (P=.661) in the second, and dropped to 1.8% in the third era (P=.043). A routine anticoagulation protocol has significantly reduced the incidence of HAT post-liver transplantation in children in a predominantly cadaveric in situ split liver transplant program.

Developing a relationship with a liver transplant program.

Developing a relationship with a liver transplant program.

Liver Transplantation is a Preferable Alternative to Palliative Therapy for Selected Patients with Advanced Hepatocellular Carcinoma.

Patients with hepatocellular carcinoma (HCC) beyond the traditional criteria (advanced HCC) are typically offered palliation, which is associated with a 3-year survival rate lower than 30%. This study aimed to describe the outcomes for a subset of patients with advanced HCC who satisfied the Extended Toronto Criteria (ETC) and were listed for liver transplantation (LT). All patients listed in the Toronto liver transplantation program with HCC beyond both the Milan and University of California, San Francisco criteria were included in this study. Data were extracted from the prospectively collected electronic database. All radiologic images were reviewed by two independent radiologists. The primary end point was patient survival. Between January 1999 and August 2014, 96 patients with advanced HCC were listed for LT, and 62 (65%) of these patients received bridging therapy while on the waiting list. Bridging therapy led to a significant reduction in tumor progression (p=0.02) and tumor burden (p<0.001). The majority of those listed underwent LT (n=69, 72%). Both tumor progression on waiting list (hazard ratio [HR] 4.973; range1.599-15.464; p=0.006) and peak alpha-fetoprotein (AFP) at 400ng/ml or higher (HR, 4.604; range 1.660-12.768; p=0.003) were independently associated with waiting list dropout. Post-LT HCC recurrence occurredin 35% of the patients (n=24). Among those with HCC recurrence, survival was significantly better for those who received curative treatment (p=0.004). The overall actuarial survival rates from the listing were 76% at 1year, 56% at 3years, and 47% at 5years, and the corresponding ratesfrom LT were 93, 71, and 66%. Liver transplantation provides significantly better survival rates than palliation for patients with selected advanced HCC.

The Romanian National Program for Liver Transplantation - 852 Procedures in 815 Patients over 17 Years (2000-2017): A Continuous Evolution to Success.

Background: Liver transplantation (LT) has become an established treatment for end-stage liver disease, with more than 20.000 procedures yearly worldwide. The aim of this study was to analyze the results of Romanian National Program of LT. Methods: Between April 2000 and April 2017, 817 pts received 852 LTs in Romania. Male/female ratio was 487/330, while adult/pediatric ratio was 753/64, with a mean age of 46 years (median 50 yrs; range 7 months - 68 yrs). Main LT indications were HBV cirrhosis (230 pts; 28.2%), HCC (173 pts; 21.2%), and HCV cirrhosis (137 pts; 16.8%). Waiting time and indications for LT, patient and donor demographics, graft features, surgical procedures, and short and long-term outcomes were analyzed. Results: DDLT was performed in 682 pts (83.9%): whole LT in 662 pts (81%), split LT in 16 pts (2.3%), reduced LT in 2 pts (0.2%), and domino LT in 1 pts (0.1%). LDLT was performed in 135 pts (16.5%): right hemiliver in 93 pts (11.4%), left lateral section in 28 pts (3.4%), left hemiliver in 8 pts (1%), left hemiliver with segment 1 in 4 pts (0.5%), and dual graft LDLT in 2 pts (0.2%). Overall major morbidity rate was 31.4% (268 pts), while perioperative mortality was 7.9% (65 pts). Retransplantation rate was 4.3% (35 pts): 27 whole LTs, 3 reduced LTs, 3 split LTs, and 2 LDLT. Long-term overall 1-, 3-, and 5-year estimated survival rates for patients were 87.9%, 81.5%, and 79.1%, respectively. One-, 3-, and 5-year overall mortality on waiting list also decreased significantly over time from 31.4%, 54.1% and 63.5%, to 4.4%, 13.9% and 23.6%, respectively. Conclusions: The Romanian National program for liver transplantation addresses all causes of acute and chronic liver failure or liver tumors in adults and children, using all surgical techniques, with good long-term outcome. The program constantly evolved over time, leading to decreased mortality rate on the waiting list.

A Report on the Positive Response to an Outdoor Nature Challenge of a Snow Camp for Young Liver Transplant Patients

ObjectivesMore than two decades have passed since the first living donor liver transplantation was performed in Japan in 1989. There are many reports about problems in adherence to taking medication and medical follow-ups in children who received liver transplants, because there is no transition strategy for those children and parents or guardians. The objective of this study is to measure the effect of nature and outdoor activity to improve children's medical adherence. MethodsWe recruited participants from 9-year-old children who are attending the outpatient liver transplant clinic in a stable condition (no event such as rejection or surgical procedure within 6 months). We took participants to a snow camp and measured its effect by using the IKIRU CHIKARA (IKR) tool, which contain 28 items divided into 3 categories: psychosocial ability, moral fitness, and physical ability. Children were tested on three occasions, before, just after, and 1 month after the camp. ResultsEight patients participated in the snow camp and 7 patients were eligible for the study. The average age was 12.6 with a range 10 to 17 years. There were 3 girls and 4 boys. The average IKR scores before, just after, and 1 month after the camp were 127.9, 131.5, and 126.6, respectively. ConclusionAn outdoor activity such as a snow camp can be safely conducted, and it is an acceptable option to incorporate within a pediatric liver transplant program. There were no significant changes in IKR scores during this short observation. Longer observation is needed to measure the effect of nature and outdoor activities.

Hospital resource intensity and cirrhosis mortality in United States.

AIMTo determine whether hospital characteristics predict cirrhosis mortality and how much variation in mortality is attributable to hospital differences.METHODSWe used data from the 2005-2011 Nationwide Inpatient Sample and the American Hospital Association Annual survey to identify hospitalizations for decompensated cirrhosis and corresponding facility characteristics. We created hospital-specific risk and reliability-adjusted odds ratios for cirrhosis mortality, and evaluated patient and facility differences based on hospital performance quintiles. We used hierarchical regression models to determine the effect of these factors on mortality.RESULTSSeventy-two thousand seven hundred and thirty-three cirrhosis admissions were evaluated in 805 hospitals. Hospital mean cirrhosis annual case volume was 90.4 (range 25-828). Overall hospital cirrhosis mortality rate was 8.00%. Hospital-adjusted odds ratios (aOR) for mortality ranged from 0.48 to 1.89. Patient characteristics varied significantly by hospital aOR for mortality. Length of stay averaged 6.0 ± 1.6 days, and varied significantly by hospital performance (P < 0.001). Facility level predictors of risk-adjusted mortality were higher Medicaid case-mix (OR = 1.00, P = 0.029) and LPN staffing (OR = 1.02, P = 0.015). Higher cirrhosis volume (OR = 0.99, P = 0.025) and liver transplant program status (OR = 0.83, P = 0.026) were significantly associated with survival. After adjusting for patient differences, era, and clustering effects, 15.3% of variation between hospitals was attributable to differences in facility characteristics.CONCLUSIONHospital characteristics account for a significant proportion of variation in cirrhosis mortality. These findings have several implications for patients, providers, and health care delivery in liver disease care and inpatient health care design.

The scope of hepatology practice outside the traditional academic medical center.

Watch a video presentation of this article The last couple of decades have seen a transformation in the practice of hepatology. From highly effective treatments for common liver diseases to significant advances in the management of decompensated cirrhosis, liver cancer, and the complications of liver transplantation, this specialty has developed a more established therapeutic role for its patients. As such, the demand for specialized liver care has grown. The need to complete clinical research in a shorter time allowed private practices to be successfully included in these trials. Collaboration with advanced diagnostic and interventional radiology, pathology, and surgery has allowed for the formation of highly functional private practice and hospital-based hepatology units. A combination of hepatology clinical practice in the office and community hospitals, clinical research, and collaboration with liver transplant centers (academic or community based), whether in a solo practice, group practice, or multispecialty practice, has also established financial viability for these private practice models. In 2014, the American Association for the Study of Liver Diseases (AASLD) created a new Special Interest Group (SIG) in Clinical Practice of Hepatology. The mission of this SIG is to provide current information and guidance on good clinical practices and practice management for providers in hepatology both in academic centers and in private practice. The aims of the Clinical Practice SIG are as follows: (1) Provide clinicians practicing hepatology with strategies to address changes in healthcare regulations, (2) develop models for creating and managing a financially viable clinical hepatology practice, (3) maintain a program for education of fellows and members on the evolution of clinical hepatology, and (4) cultivate professional relationships and programs between physicians practicing hepatology and liver transplant programs. The SIG held its first symposium at the 2015 AASLD Liver Meeting; it focused on describing the different models that have been successful outside of the traditional academic center. A discussion of these presentations follows in this paper. We also held a webinar on coding and billing in 2015. In 2016 we will hold the second SIG symposium at the 2016 Liver Meeting, this time focusing on financial aspects of managing and growing a hepatology clinical practice. We look forward to expanding this work to fill an area of need in communities all over the United States and offer new career opportunities to young physicians trained in hepatology.

Gamble on the Uncertain. Negotiating Medical Decision-Making

The aim of this paper is to analyze the medical decision-making process in the admission of patients into a Liver Transplant Program in a hospital in Lisbon, Portugal. The relationships and main strategies established among the medical specializations involved in this process will be investigated. The theoretical basis was drawn from medical sociology, in particular, from the social constructivist approaches, which highlight the relation between medical power and knowledge in the construction of medical decision-making. I attempt to elucidate the processes of negotiation through which a medical decision is constructed. The research methodology included non-participant observation and semi-structured interviews with participants from the two medical specializations of interest: liver surgeons and hepatologists. The management of risk and uncertainty in relation to patients’ access to liver transplantation is discussed and the strategic alliances that are formed during medical decision-making in search of consensus are investigated. The research findings show that medical practices and knowledge do not converge linearly to produce a coherent network of actions with a view to decision-making. Instead, medical decision-making is constructed through complex processes of negotiation. The different natures and levels of uncertainty and indetermination that are inherent in the social world of medicine have a fundamental influence on medical decision-making.

Biliary atresia in Vietnam: Management and the burden of disease

Biliary atresia is an idiopathic, neonatal liver disease of the bile ducts. The natural evolution of biliary atresia is known in developed countries. This study describes the clinical course of biliary atresia in Vietnam, a developing country. Chart reviews were undertaken of patients treated with or without the Kasai procedure between January 2010 and July 2013 at a children's hospital in Vietnam. Of 287 children with biliary atresia, 149 (52%) were treated without the Kasai procedure and 138 (48%) were treated with the Kasai procedure. Median age at diagnosis was 2.4months for children treated without the Kasai procedure vs 2.3months for those treated with the procedure. The percentages of patients in the group treated without the Kasai procedure presenting at <2months, 2 to <3months, 3 to <4months, 4-6months, and >6months of age were 31%, 35%, 15%, 10%, and 9%, respectively, compared to those treated with the Kasai procedure at 36% (P=.38), 44% (P=.12), 16% (P=1.0), 4% (P=.037), and 0% (P<.001), respectively. The group treated without the Kasai procedure had 1- and 2-year survivals of 52% and 28%, respectively (median survival 6.6months); in contrast, the group treated with the Kasai procedure had 1- and 2-year transplant-free survivals of 84% and 71%. No patients were treated by liver transplantation because of lack of a liver transplantation program in Vietnam. The majority of biliary atresia in Vietnam remains untreated despite early presentation and reasonable outcomes after a Kasai procedure relative to Western countries. These data illustrate the high health care burden for biliary atresia in Vietnam and the need to improve education about biliary atresia and its treatment.

Neuropsychological functioning in preschool-aged children undergoing evaluation for organ transplant

Objective: The purpose of this study was to review the current literature on neuropsychological functioning in two groups of children requiring organ transplants (liver or heart) and present recent clinical data collected through the liver and cardiac transplantation programs at a large pediatric academic medical center. Method: Data included in this study came from 18 patients who completed evaluations for heart transplant (n = 8) or liver transplant (n = 10) between the ages of 2 and 6 years (inclusive). Measures examining neurocognitive, emotional-behavioral, and adaptive functioning were collected as part of standard pre-transplant clinical neuropsychological evaluations. Within each organ group, mean scores were calculated and compared with normative population mean scores using one sample t-tests. In addition, non-parametric binomial tests were calculated to examine whether the proportion of individuals falling more than one standard deviation below the population mean was significantly greater in the patient groups than the normative population base rate of 16%. Results: Patients in both groups performed below normative expectation in several neurocognitive and adaptive domains. However, neither group showed significant difficulties in behavioral or emotional regulation. Conclusions: Results from this study document cognitive delays in preschool-aged children undergoing evaluations for liver transplant or heart transplant, highlighting the importance of intervention and long-term monitoring of these two patient populations, as well as the need for neuropsychologist involvement with transplant teams.

Should quality of the liver transplant candidate evaluation be measured?

Should quality of the liver transplant candidate evaluation be measured?