Mortality In Liver Transplant Patients Research Articles

Mortality rate after total knee arthroplasty or total hip arthroplasty in patients with a history of liver transplant

In this editorial I comment on the article by Ahmed et al published in a recent issue of the World J Orthop 2023; 14: 784-790. It is well known that patients who have undergone a liver transplant (LT) may need to have a total hip arthroplasty (THA) or total knee arthroplasty (TKA) implanted. Ahmed et al stated that the mortality rate in these patients was similar to the one of the general population. However, there are three articles previously published that found higher mortality in LT patients who experienced THA/TKA than in the general population (individuals without LT). Therefore, in this Editorial I would like to point out that there is controversy in the literature regarding whether LT patients undergoing THA/TKA have higher mortality than the general population. Therefore, future research should attempt to resolve this controversy.

Multidrug-Resistant Infections After Liver Transplantation, Etiology and Risk Factors: A Single-Center Experience.

Patients undergoing liver transplant are at an increased risk of morbidity and mortality due to the development of infections. We aimed to evaluate the risk factors affecting the incidence of infectious diseases after liver transplant and to present the epidemiological data. We investigated patients aged ≥18 years who underwent liver transplant between 2012 and 2020 at our center. We collected infections, causative microorganisms, and antibacterial resistance patterns seen during the first 6 months posttransplant. Risk factors affecting the development of infectious diseases were also analyzed and evaluated. Of 112 patients included in our study, 76 (67.9%) were men, and the median age was 50 years (range, 20-66 years). Within month 1 and month 6 after transplant, at least 1 episode of infection occurred in 67 (59.8%) and 80 (71.4%) patients, respectively. Bacterial infections were the most common type (n = 78, 95.1%), followed by fungal (n = 2, 2.4%) and viral (n = 2, 2.4%) infections. The rate of multidrug resistance in bacterial infections was high (n = 38, 52.7%) and was also a risk factor for mortality in the first 6 months after transplant (P < .001). Pretransplant values of international normalized ratio, creatinine, bilirubin, and posttransplant intensive care unit stay, as well as the presence of encephalopathy, were shown to increase the risk of infection after transplant. Multidrug-resistant bacterial infections are a significant risk factor for mortality in liver transplant patients. Many risk factors that contribute to the development of infections aftertransplant have been included in prognostic scoring systems of liver failure. Consequently, the severity of end-stage liver failure is directly related to the risk of posttransplant infections.

Diabetes and Metabolic Disorders: Their Impact on Cardiovascular Events in Liver Transplant Patients.

Cardiovascular diseases are currently one of the most important causes of morbidity and mortality in liver transplant patients over the long term. Therefore, evaluating prognostic factors for cardiovascular events (CVEs) in this population is essential for taking preventive measures. The aim of this study was to identify the impact of diabetes and other metabolic disorders on CVEs in liver transplant patients. Three hundred fifty-six liver transplant recipients who survived at least 6 months after surgery were enrolled. Patients were followed for a median time of 118 months (12-250 months). All cardiovascular events were carefully recorded and detailed in the patients' charts. Demographic data, diabetes, hypertension, dyslipidemia, weight changes, and a diagnosis of metabolic syndrome both before and after transplantation were noted to assess their possible relationship with CVE. The presence of a diagnosis of metabolic-associated fatty liver disease (MAFLD) was also evaluated. Immunosuppressive therapy was included in the analysis. Diabetes mellitus (DM), especially when present before transplantation, was strongly associated with CVEs (hazard risk HR 3.10; 95% confidence interval CI: 1.60-6.03). Metabolic syndrome was found to be associated with CVEs in univariate analysis (HR 3.24; 95% CI: 1.36-7.8), while pretransplantation and de novo MAFLD were not. Immunosuppressive therapy had no influence on predisposing transplanted patients to CVEs during follow-up. Further prospective studies may be useful in investigating the risk factors for CVEs after liver transplantation and improving the long-term survival of transplant patients.

Alcohol as a risk factor for mortality in liver transplant patients in Sweden

Objectives Liver transplantation (LT) is the only available cure for end-stage liver disease and one of the best treatment options for hepatocellular carcinomas (HCC). Patients with known alcohol-associated cirrhosis (AC) are routinely assessed for alcohol dependence or abuse before LT. Patients with other liver diseases than AC may consume alcohol both before and after LT. The aim of this study was to assess the effects of alcohol drinking before and after LT on patient and graft survival regardless of the etiology of liver disease. Materials and Methods Between April 2012 and December 2015, 200 LT-recipients were interviewed using the Lifetime Drinking History and the Addiction Severity Index questionnaire. Patients were categorized as having AC, n = 24, HCC and/or hepatitis C cirrhosis (HCV), n = 69 or other liver diseases, n = 107. Patients were monitored and interviewed by transplantation-independent staff for two years after LT with questions regarding their alcohol consumption. Patient and graft survival data were retrieved in October 2019. Results Patients with AC had an increased hazard ratio (HR) for death after LT (crude HR: 4.05, 95% CI: 1.07–15.33, p = 0.04) and for graft loss adjusted for age and gender (adjusted HR: 3.24, 95% CI 1.08–9.77, p = 0.04) compared to the other patients in the cohort. There was no significant effect of the volume of alcohol consumed before or after LT on graft loss or overall survival. Conclusion Patients transplanted for AC have a worse prognosis, but we found no correlation between alcohol consumed before or after LT and graft or patient survival.

211.11: Evaluating the Impact of Kidney Transplant Timing on Postoperative Dialysis Requirement and Mortality in Liver Transplant Patients: A Single Center Experience

211.11: Evaluating the Impact of Kidney Transplant Timing on Postoperative Dialysis Requirement and Mortality in Liver Transplant Patients: A Single Center Experience

S1066 COVID-19 in Liver Transplant Recipients: Results of the National COVID Cohort Collaborative (N3C)

Introduction: SARS-CoV-2 infection has resulted in significant mortality in liver transplant (LT) recipients based on available data thus far. Larger and more varied datasets are required to improve our understanding of the risks from SARS-CoV-2 faced by liver transplant recipients. The National COVID Cohort Collaborative (N3C) Enclave was developed to facilitate analysis of patient-level data across the US for multiple conditions, consisting of weekly electronic medical record data extraction and transmission into the federally secured platform. Herein is our report of the N3C cohort of US COVID-19 positive LT patients to date. Methods: We identified a cohort of LT recipients who received a positive COVID-19 test (COVID+) between 1/1/2020 and 3/30/2021. We evaluated mortality outcomes and predictive risk factors for death. We used univariate and multivariate models to analyze the variable-outcome associations. The primary outcome was in-hospital mortality. Survival analysis methods were used to estimate cumulative incidences of death and mechanical ventilation, and to calculate the associations of COVID-19 infection and demographic and clinical factors to mortality in LT patients. Results: 34 sites account for 6.3 million patients in the Enclave, of whom 2.1 million are COVID+. A total of 300 post-LT patients with COVID-19 were included in the analysis. The in-hospital mortality rate in LT COVID+ patients was approximately 7%. Hyperlipidemia, coronary artery disease (CAD) and chronic kidney disease (CKD) were common comorbidities in COVID+ LT recipients, but significantly more common in those who died. In univariate analysis, age, albumin level, CKD, CAD, hyperlipidemia, sepsis, acute kidney injury (AKI), prednisone use and mechanical ventilation were statistically significant in predicting death (p< 0.001). In multivariate analysis, only age, albumin level, prednisone use and mechanical ventilation remained statistically significant (p=0.02). Conclusion: In this study of a US cohort of COVID+ LT recipients using the N3C database, we found that mortality rate in post-LT patients with COVID-19 infection is approximately 7%. In our final predictive model, age, mechanical ventilation, and low albumin level were associated with higher risk of death. In contrast, prednisone use was associated with reduced mortality. Those factors are not only predictive, but also potentially prognostic and thus may assist with the management of COVID+ LT patients.

Alcohol-related cirrhosis is associated with high coronary artery calcium scores in patients undergoing evaluation for orthotopic liver transplantation.

Coronary artery disease is a major cause of morbidity and mortality in liver transplant patients. Coronary artery calcium (CAC) score has been used to evaluate the risk of CAD in non-cirrhotic patients. However, its significance in cirrhotic patients is unknown. This study aimed to identify factors associated with elevated CAC scores in patients with end-stage liver disease undergoing liver transplant evaluation. We retrospectively reviewed all patients who underwent liver transplantation evaluation and had coronary CT scan between January 2015 and December 2018. Patients with prior history of CAD were excluded. CAC score was calculated based on the method described by Agatston. Sixty-two patients were included. 37.1% had alcohol-related liver disease and 27.4% had NASH cirrhosis. Mean CAC score was 261.1±SD, 463.84. Alcohol-related liver disease, male gender, and hypertension were significantly associated with CAC score >100 and only alcohol-related liver disease was associated with CAC score >300. In logistic regression, patients with alcohol-related liver disease had more than sixfold increase in risk of having CAC scores >100 and 300 (OR 6.14, and 6.70, respectively). Alcohol-related liver disease, male gender, and hypertension were significantly associated with an increased CAC score >100. However, alcohol-related liver disease was the only factor associated with CAC score >300.

Outcomes of Infection and Risk of Mortality in Liver Transplant Patients with Simultaneous Splenectomy

PurposeThe purpose of this study was to compare the outcomes of infection between liver transplant patients with and without simultaneous splenectomy. MethodsWe retrospectively analyzed the records of 211 patients who underwent liver transplantation in the Tri-Service General Hospital from 2012 to 2017. The frequency of blood cultures obtained after liver transplantation; incidence of bacteremia, pathogens, and complications; and overall survival rates were compared between the groups. ResultsOne hundred thirty-three of 211 patients underwent liver transplantation without simultaneous splenectomy. There were no significant differences in the frequency of blood cultures obtained after liver transplantation (non-splenectomy group and splenectomy group: 63% and 62%, respectively); incidences of bacteremia after liver transplantation (21% and 21%, respectively), repeat bacteremia (39% and 35%, respectively), cytomegalovirus infection (4% and 3%, respectively), herpes infection (6% and 7%, respectively), and fungal infection (3% and 3%, respectively); and overall survival rate between the two groups. However, there was a significant difference in infection-related deaths between the groups. Simultaneous splenectomy and episodes of antibody-related rejection were significant risk factors associated with infection-related death in multivariate analyses. ConclusionAlthough simultaneous splenectomy does not increase the incidence of infection, simultaneous splenectomy definitely carries risks of infection-related mortality in liver transplantation.

The Impact of Previous Abdominal Surgery in a High-Acuity Liver Transplant Population

BackgroundIt is not uncommon for liver transplant (LT) recipients to have had previous abdominal surgery (PAS) preceding transplant. The impact of PAS on morbidity and mortality in LT patients remains unclear. In this study, we investigated the correlation between PAS and LT outcomes in a high-acuity patient population. Materials and methodsThis is a single-center retrospective review of 936 adult primary LT recipients between 2012 and 2018. Patients were divided based on PAS history. PAS was subdivided into upper abdominal surgery (UAS) and lower abdominal surgery (LAS). UAS was separated into high-impact UAS and low-impact UAS. Finally, we studied patients with PAS ≤90 d versus PAS >90 d. ResultsExtensive adhesiolysis was the only significant perioperative factor between the PAS group (n = 367) and the non-PAS group (n = 569) (P < 0.001). Red blood cell (RBC) transfusion (20U versus 17U, P = 0.044) and abdominal packing (24.2% versus 13.3%, P = 0.008) were significantly higher in the UAS group (n = 186) versus the LAS group (n = 181). Patients with high-impact UAS required greater RBC (P = 0.021) and fresh frozen plasma transfusion (P = 0.005), and arterial conduits (P = 0.016) during LT. Compared with recipients with PAS >90 d (n = 338), recipients with PAS ≤90 d (n = 29) had significantly higher RBC transfusion (P = 0.046), fresh frozen plasma transfusion (P = 0.022), and abdominal packing (P = 0.025). No differences in patient and graft survival was observed. ConclusionsThese findings suggest that, with appropriate care in the perioperative setting, PAS is not a contraindication to successful LT. Careful consideration is warranted when risk stratifying patients with multiple comorbidities who had PAS, especially those with UAS or PAS ≤90 d.

S1008 STEMI-Induced Mortality in Liver Transplant Patients, Trends in Mortality, Associated Clinical Factors, Co-Morbidities and Management: A Report on NIS Data Analysis From 2012-2017

INTRODUCTION: ST elevation myocardial infarction (STEMI) induced mortality is decreasing nationwide, however no report to date has examined STEMI mortality in liver transplant patients. We sought to examine the prevalence and trend of STEMI induced mortality, associated clinical factors, comorbidities, and treatment modalities used in liver transplant patients. METHODS: This is a retrospective cohort study of 318 liver transplant patients hospitalized with STEMI across the United States from 1/1/ 2012 to 12/31/2017. Patients were selected from NIS database using ICD codes 9 and 10. Descriptive statistics, student’s t-test and, chi square tests were used to analyze the data. Both males and females age 18 and above with urgent and emergent hospitalizations were included in the study. Primary outcome was in-hospital death. Potential confounders were age, sex, race, insurance type, admission day and, disposition. RESULTS: Mean age of the studied population was 62.3 ± 10.6 years. 27.8% (n = 88) were females and 84% were Caucasians. 64.3% of patients (n = 204) were managed with CABG and PCI vs 35.7% managed medically. During hospitalization, mortality rate was 11.3% (n = 36). Patients who died were relatively old (65.2 ± 7.1 vs. 61.9 ± 10.9, P-value: 0.02) and predominantly males (13.5% vs. 5.7%, P-value: 0.045). There was no statistically significant difference in mortality across different races (white: 12.8% vs. 13.6% non-white, P-value: 0.88). Prevalence of CHF (30% vs 10%, P < 0.001), coagulopathy (31% vs 8%) and, PVD (28% vs 10%, P: 0.01) was higher in deceased patients. There was an increase in trend noted in percentage of procedures (PCI and CABG) over the years (2002-2005: 42%, 2006-2009: 40%, 2010-2013:70%, 2014–2017: 79%, P value < 0.001). There was no difference in mean age between patients with and without procedures, however length of stay was longer 8 vs 3 days (P < 0.001) and hospitalization charges were higher $172144 vs $49977 (P < 0.001) in procedure group as comparted to medical management group. CONCLUSION: Mortality rate of STEMI in liver transplant patients is higher relative to general patient population (11.3% vs 10%). Patients who died were relatively old, predominantly males, and of Caucasian descent. There was an increase trend for procedures (CABG/ PCI) performed compared to medical management in transplant STEMI patients from 2002 to 2017.

Impact of COVID-19 on the care of patients with liver disease: EASL-ESCMID position paper after 6 months of the pandemic.

SummaryDuring the early stages of the coronavirus disease 2019 (COVID-19) pandemic, EASL and ESCMID published a position paper to provide guidance for physicians involved in the care of patients with chronic liver disease. While some healthcare systems are returning to a more normal routine, many countries and healthcare systems have been, or still are, overwhelmed by the pandemic, which is significantly impacting on the care of these patients. In addition, many studies have been published focusing on how COVID-19 may affect the liver and how pre-existing liver diseases might influence the clinical course of COVID-19. While many aspects remain poorly understood, it has become increasingly evident that pre-existing liver diseases and liver injury during the disease course must be kept in mind when caring for patients with COVID-19. This review should serve as an update on the previous position paper, summarising the evidence for liver disease involvement during COVID-19 and providing recommendations on how to return to routine care wherever possible.

Determining risk factors for mortality in liver transplant patients with COVID-19

Determining risk factors for mortality in liver transplant patients with COVID-19

Liver Transplantation and Early Culture Growth: Risk and Impact?

ObjectiveDespite advances in immunosuppressive drugs, postoperative care, and surgical techniques, bacterial infections remain the most important cause of morbidity and mortality in liver transplant patients. The aim of this study is to evaluate the influence of culture results taken on the first day of admission to intensive care unit on mortality, graft rejection, mechanical ventilation duration, and length of intensive care unit stay. Our study has clinical importance because it is the first study evaluating the cultures obtained on the first day of intensive care unit stays in liver transplant patients. MethodsPatients' demographic data, transplant type, rates of deceased and living donors, culture results, amount of blood and blood products used intraoperatively, previous hospital admission, mortality, incidence of graft rejection, mechanical ventilation duration, and length of intensive care unit stay were recorded. ResultsMortality and graft rejection were 14.8% and 9%, respectively. The mortality was significantly higher in all 3 cultures and/or in only blood culture–positive patients. Graft rejection, mechanical ventilation duration, and length of intensive care unit stay were significantly higher in patients whose 3 cultures were all positive. Only body mass index had a significant effect on mortality, graft rejection, and positive culture results. ConclusionsLiver transplant patients' first postoperative day culture results were correlated with mortality, graft rejection, mechanical ventilation duration, and length of intensive care unit stay.

SOFA Score Can Effectively Predict the Incidence of Sepsis and 30-Day Mortality in Liver Transplant Patients: A Retrospective Study.

This study aims to evaluate the early predictive value for postoperative sepsis and 30-day mortality in liver transplant patients using sequential organ failure assessment (SOFA). A total of 96 liver transplant patients were enrolled into this study from February 2015 to June 2018. The general information, biochemical findings, and postoperative 30-day mortality of these patients were statistically analyzed. The SOFA scores, C-reactive protein (CRP), and procalcitonin (PCT) at postoperative day (POD) 3, 5, and 7 were significantly higher in the sepsis group than in the non-sepsis group, and the differences were statistically significant. Receiver operating characteristic (ROC) curve showed that SOFA scores at POD 1, 3, 5, and 7 had higher sensitivity and specificity in predicting the incidence of sepsis within 30days. The difference in 30-day survival rate between patients with SOFA scores of > 5 and patients with SOFA scores of ≤ 5 at POD 1-7 was statistically significant (P < 0.05). SOFA scores at POD 1-7 can effectively predict the incidence of sepsis and 30-day mortality in liver transplant patients on the basis of CRP and PCT.

Midodrine conveys increased risk for waitlist mortality in liver transplant patients

Midodrine conveys increased risk for waitlist mortality in liver transplant patients

Risk Factors for Early Mortality in Liver Transplant Patients

BackgroundLiver 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 long-term outcomes. The aim of this study is to correlate specific surgical and anesthesiological variables with causes of early death in LT recipients. MethodsA 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. ResultsStatistically 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. ConclusionsThis 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.

Relation of Preoperative and Postoperative Echocardiographic Parameters With Rejection and Mortality in Liver Transplant Patients.

Survival in liver transplant after end-stage liver disease is associated with major cardiac functions. In a significant number of patients with end-stage liver disease, cardiac dysfunctions may be observed, which can include high-output heart failure, cardiac valve disease, and pulmonary venous and arterial hypertension. All of these affect perioperative survival. The aim of our study was to determine whether preoperative and postoperative echocardiographic parameters, specifically right heart-related tricuspid regurgitation, estimated systolic pulmonary arterial pressure, and tricuspid annular plane systolic excursion, are associated with rejection and mortality in liver transplant patients. Adult patients (> 18 years old) who underwent liver transplant at our center between January 2011 and March 2017 were included in the study, with 64 patients retrospectively screened. The echocardiographic images that were taken immediately before and immediately after liver transplant were evaluated. The patients were divided into 2 groups according to rejection data and mortality. All parameters were analyzed for both variables. For the 24 patients with liver rejection and 40 patients without liver rejection, there were no statistically significant differences in terms of demographic data, echocardiographic parameters, and laboratory data. However, when patients were evaluated according to survival, there was a statistically significant difference between these 2 groups concerning the echocardiography parameters of systolic pulmonary arterial pressure (P = .005), tricuspid annular plane systolic excursion (P = .001), and postoperative right ventricular width (P = .01). Echocardiography, being a simple and easily accessible technique that is reliable in excluding pulmonary hypertension diagnosis, can be used as a guide in the evaluation of right ventricular function and tricuspid regurgitation, particularly in patients who are not hemodynamically stable before and after liver transplant.

Comparison of APACHE IV with APACHE II, SAPS 3, MELD, MELD-Na, and CTP scores in predicting mortality after liver transplantation

The Acute Physiology and Chronic Health Evaluation (APACHE) IV score and Simplified Acute Physiology Score (SAPS) 3 include liver transplantation as a diagnostic category. The performance of APACHE IV-liver transplantation (LT) specific predicted mortality, SAPS 3, APACHE II, Model for End-stage Liver Disease (MELD)-Na, MELD, and CTP scores in predicting in-hospital and 1 year mortality in liver transplant patients was compared using 590 liver transplantations in a single university hospital. In-hospital mortality and 1 year mortality were 2.9% and 4.2%, respectively. The APACHE IV-LT specific predicted mortality showed better performance in predicting in-hospital mortality (AUC 0.91, 95% CI [0.86–0.96]) compared to SAPS 3 (AUC 0.78, 95% CI [0.66–0.90], p = 0.01), MELD-Na (AUC 0.74, 95% CI [0.57–0.86], p = 0.01), and CTP (AUC 0.68, 95% CI [0.54–0.81], p = 0.01). The APACHE IV-LT specific predicted mortality showed better performance in predicting 1 year mortality (AUC 0.83, 95% CI [0.76–0.9]) compared to MELD-Na (AUC 0.67, 95% CI [0.55–0.79], p = 0.04) and CTP (AUC 0.64, 95% CI [0.53–0.75], p = 0.03), and also in all MELD groups and in both living and deceased donor transplantation. The APACHE IV-LT specific predicted mortality showed better performance in predicting in-hospital and 1 year mortality after liver transplantation.

Sa1635 Cardiac Events in the 30 Day Postoperative Period Are Associated With Increased One-Year Mortality in Liver Transplant Patients

Sa1635 Cardiac Events in the 30 Day Postoperative Period Are Associated With Increased One-Year Mortality in Liver Transplant Patients

Predictive value of psychosocial assessment for the mortality of patients waiting for liver transplantation

Selecting suitable candidates for liver transplantation is the most challenging task of pre-transplant evaluation. In addition to somatic assessment, psychosocial evaluation has been proven important in identifying patients at high risk of potential failure. The Transplant Evaluation Rating Scale (TERS) is a widely used rating instrument for the assessment of psychosocial risk factors before liver transplantation. The aim of this study was to explore the predictive value of TERS for mortality in liver transplant patients before and after transplantation. The medical records of patients referred for psychiatric evaluation before liver transplantation between 2003 –2013 were analysed. Administering TERS was part of the pre-transplant evaluation. The TERS scores of patients who died before and after transplantation were compared with those who survived following transplantation. One hundred and sixteen patients were referred for pre-transplant psychiatric evaluation. Patients with successful liver transplants scored significantly lower on TERS than those who died before transplantation (30.65 ± 6.06 vs. 34.75 ± 8.25, p = .031). Patients who died after transplantation scored significantly better on TERS than those who died before transplantation (28.79 ± 2.81 vs. 34.75 ± 8.25, p = .003). There was no significant difference between the deceased and surviving transplanted patients’ TERS scores (28.79 ± 2.81 vs. 31.19 ± 6.66, p = .365). TERS appears to be a suitable rating instrument to help select candidates who have higher chance to survive prior to transplantation but it could not predict post-transplant mortality.