Primary Liver Transplantation Research Articles

Milan Criteria, University of California, San Francisco, Criteria, and Model for End-Stage Liver Disease Score as Predictors of Salvage Liver Transplantation

The selection criteria for salvage liver transplantation (SLT) candidates have not been previously established. A global analysis for the association between the criteria and prognosis is required. All of the adult patients who underwent liver transplantation with a diagnosis of hepatocellular carcinoma (HCC) from January 1, 2000, to December 31, 2011, were retrospectively analyzed. A total of 1,554 cases were involved, including 1,392 primary liver transplantation (PLT) and 162 SLT cases. All the cases were classified into 3 groups according to the Milan criteria combined with the University of California, San Francisco (UCSF), criteria, and significant differences were found between the 2 groups. The overall graft survival rate was lower in all cases of SLT than in PLT (P = .030). Within the Milan criteria, no significant difference in the graft survival rate was found between PLT and SLT. In a Cox regression analysis, the Model for End-Stage Liver Disease (MELD) score and tumor levels graded according to the Milan/UCSF criteria were found to be independent risk factors for the graft survival rate. Receiver operating characteristic (ROC) curves were generated by the fatality risk values calculated by means of the Cox model and the 1-year graft survival rates of all the patients and of the SLT patients. The areas under the ROC curves were 0.922 and 0.935, respectively. Compared with PLT, the global graft survival rate of SLT was compromised. The MELD score and Milan/UCSF criteria were effective in predicting the prognosis of PLT and SLT. Therefore, when the recurrent lesions of HCC are within the Milan criteria, SLT can be performed with a good prognosis.

Morbid obesity in liver transplant recipients adversely affects longterm graft and patient survival in a single‐institution analysis

ObjectiveThe effects of obesity in liver transplantation remain controversial. Earlier institutional data demonstrated no significant difference in postoperative complications or 1‐year mortality. This study was conducted to test the hypothesis that obesity alone has minimal effect on longterm graft and overall survival. MethodsA retrospective, single‐institution analysis of outcomes in patients submitted to primary adult orthotopic liver transplantation was conducted using data for the period from 1 January 2002 to 31 December 2012. Recipients were divided into six groups by pre‐transplant body mass index (BMI), comprising those with BMIs of <18.0 kg/m2, 18.0–24.9 kg/m2, 25.0–29.9 kg/m2, 30.0–35.0 kg/m2, 35.1–40.0 kg/m2 and >40 kg/m2, respectively. Pre‐ and post‐transplant parameters were compared. A P‐value of <0.05 was considered to indicate statistical significance. Independent predictors of patient and graft survival were determined using multivariate analysis. ResultsA total of 785 patients met the study inclusion criteria. A BMI of >35 kg/m2 was associated with non‐alcoholic steatohepatitis (NASH) cirrhosis (P < 0.0001), higher Model for End‐stage Liver Disease (MELD) score, and longer wait times for transplant (P = 0.002). There were no differences in operative time, intensive care unit or hospital length of stay, or perioperative complications. Graft and patient survival at intervals up to 3 years were similar between groups. Compared with non‐obese recipients, recipients with a BMI of >40 kg/m2 showed significantly reduced 5‐year graft (49.0% versus 75.8%; P < 0.02) and patient (51.3% versus 78.8%; P < 0.01) survival. ConclusionsObesity increasingly impacts outcomes in liver transplantation. Although the present data are limited by the fact that they were sourced from a single institution, they suggest that morbid obesity adversely affects longterm outcomes despite providing similar short‐term results. Further analysis is indicated to identify risk factors for poor outcomes in morbidly obese patients.

Potential role of the donor in hepatocellular carcinoma recurrence after liver transplantation.

A subset of liver transplantation (LT) recipients who undergo transplantation for hepatocellular carcinoma (HCC) will develop postoperative recurrence. There has yet to be a thorough investigation of donor factors influencing recurrence. Data regarding adult, primary LT recipients with HCC (n = 5002) who underwent transplantation between January 1, 2006 and September 30, 2010 were extracted from the United Network for Organ Sharing database, and the cumulative incidence of post-LT recurrence by donor factors was subsequently estimated. Among the HCC LT recipients, 324 (6.5%) developed recurrence. An analysis of donor characteristics demonstrated a higher cumulative incidence of recurrence within 4 years of transplantation among recipients with donors ≥ 60 years old (11.8% versus 7.3% with donors < 60 years old, P < 0.001) and with donors from a nonlocal share distribution (10.6% versus 7.4% with donors with a local share distribution, P = 0.004). The latter 2 findings held true in a multivariate analysis: the risk of HCC recurrence increased by 70% for recipients of livers from donors ≥ 60 years old [subhazard ratio (SHR) = 1.70, 95% confidence interval (CI) = 1.31-2.20, P < 0.001] and by 42% for recipients of nonlocal share distribution livers (SHR = 1.42, 95% CI = 1.09-1.84, P = 0.009) after adjustments for clinical characteristics. In conclusion, the consideration of certain donor factors may reduce the cumulative incidence of posttransplant HCC recurrence and thus improve long-term survival after LT.

Surgical treatment of intra hepatic recurrence of hepatocellular carcinoma.

Recurrence after hepatocellular carcinoma (HCC) is frequent. Currently, there are no recommendations on therapeutic strategy after recurrence of HCC. Whereas the 5 year-recurrence rate after resection of HCC is 100%, this drops to 15% after primary liver transplantation. Repeat hepatectomy and salvage liver transplantation (SLT) could be performed in selected patients to treat recurrent HCC and enable prolonged overall survival after treatment of recurrence. Other therapies such as local ablation, chemoembolization or sorafenib could be proposed to those patients unable to benefit from resection or SLT. A clear definition of the place of SLT and "prophylactic" liver transplantation is required. Indeed, identifying risks factors for recurrence at time of primary liver resection of HCC may help to avoid recurrence beyond Milan criteria and non-resectable situations. In this review, we summarize the recent data available in the literature on the feasibility and outcomes of repeat hepatectomy and SLT as treatment for recurrent HCC.

Treatment of HCV prior to liver transplantation to prevent HCV recurrence - wise or wasteful?

Treatment of HCV prior to liver transplantation to prevent HCV recurrence - wise or wasteful?

Emerging trends in hepatocellular carcinoma incidence and mortality.

The rise in incidence of hepatocellular carcinoma (HCC) in the United States has been well documented. The purpose of this analysis was to examine temporal trends in HCC incidence, mortality, and survival within the U.S. population. The Surveillance, Epidemiology, and End Results data were used to examine incidence and incidence-based (IB) mortality in HCC from 1973 to 2011. Secular trends in age-adjusted incidence and IB mortality by sex and cancer stage were characterized using the Joinpoint Regression program. In 1973, HCC incidence was 1.51 cases per 100,000, whereas in 2011, HCC incidence was 6.20 cases per 100,000. Although HCC incidence continues to increase, a slowing of the rate of increase occurs around 2006. In a sensitivity analysis, there was no significant increase in incidence and IB mortality from 2009 to 2011. There was a significant increase in overall median survival from the 1970s to 2000s (2 vs. 8 months; P < 0.001). On multivariable Cox's regression analysis, age, sex, race, tumor grade, stage at diagnosis, lymph/vascular invasion, number of primary tumors, tumor size, and liver transplant were independently associated with mortality. Our results indicate a deceleration in the incidence of HCC around 2006. Since 2009 and for the first time in four decades, there is no increase in IB mortality and incidence rates for HCC in the U.S. population. The nonsignificant increase in incidence and IB mortality in recent years suggest that the peak of the HCC epidemic may be near. A significant survival improvement in HCC was also noted from 1973 to 2010, which seems to be driven by earlier detection of HCC at a curative stage and greater utilization of curative modalities (especially transplant).

Early occurrence of new-onset diabetes after transplantation is related to type of liver graft and warm ischaemic injury.

We studied new-onset diabetes after transplantation (NODAT) in liver transplantation with grafts donated after brain death (DBD) or circulatory death (DCD), focusing on the early post-transplant period. A total of 430 non-diabetic primary liver transplant recipients [DCD, n = 90 (21%)] were followed up for 30 months (range 5-69). NODAT was defined as the composite endpoint of one of following: (i) Two non-fasting plasma glucose levels > 11.1 mmol/L ≥ 30 days apart, (ii) oral hypoglycaemic drugs ≥ 30 days consecutively (iii) insulin therapy ≥ 30 days and (iv) HbA1c ≥ 48 mmol/L. Resolution of NODAT was defined as cessation of treatment or hyperglycaemia. Total of 81/430 (19%) patients developed NODAT. Incidence and resolution of NODAT over time showed significantly different patterns between DCD and DBD liver graft recipients; early occurrence, high peak incidence and early resolution were seen in DCD. In multivariate logistic regression including age, ethnicity, HCV, tacrolimus level and pulsed steroids, only DCD was independently associated with NODAT at day 15 post-transplant (OR 6.5, 95% CI 2.3-18.4, P < 0.001), whereas age and pulsed steroids were significant factors between 30-90 days. Combined in multivariate Cox regression model for NODAT-free survival, graft type, age and pulsed steroids were each independent predictor for decreased NODAT-free survival in the first 90-postoperative days. Early peak of NODAT in DCD graft recipients is a novel finding, occurring independently from known risk factors. Donor warm ischaemia and impact on insulin sensitivity should be further studied and could perhaps be associated with graft function.

High early cardiovascular mortality after liver transplantation.

Cardiovascular disease (CVD) contributes to excessive long-term mortality after liver transplantation (LT); however, little is known about early postoperative CVD mortality in the current era. In addition, there is no model for predicting early postoperative CVD mortality across centers. We analyzed adult recipients of primary LT in the Organ Procurement and Transplantation Network (OPTN) database between February 2002 and December 2012 to assess the prevalence and predictors of early (30-day) CVD mortality, which was defined as death from arrhythmia, heart failure, myocardial infarction, cardiac arrest, thromboembolism, and/or stroke. We performed logistic regression with stepwise selection to develop a predictive model of early CVD mortality. Sex and center volume were forced into the final model, which was validated with bootstrapping techniques. Among 54,697 LT recipients, there were 1576 deaths (2.9%) within 30 days. CVD death was the leading cause of 30-day mortality (40.2%), and it was followed by infection (27.9%) and graft failure (12.2%). In a multivariate analysis, 9 significant covariates (6 recipient covariates, 2 donor covariates, and 1 operative covariate) were identified: age, preoperative hospitalization, intensive care unit status, ventilator status, calculated Model for End-Stage Liver Disease score, portal vein thrombosis, national organ sharing, donor body mass index, and cold ischemia time. The model showed moderate discrimination (C statistic = 0.66, 95% confidence interval = 0.63-0.68). In conclusion, we provide the first multicenter prognostic model for the prediction of early post-LT CVD death, the most common cause of early post-LT mortality in the current transplant era. However, evaluations of additional CVD-related variables not collected by the OPTN are needed in order to improve the model's accuracy and potential clinical utility.

Sofosbuvir and Ribavirin for Treatment of Compensated Recurrent Hepatitis C Virus Infection After Liver Transplantation

Interferon alfa-based regimens used to treat recurrent hepatitis C virus (HCV) infection after liver transplantation are poorly tolerated, associated with generally modest efficacy, and can interact with immunosuppressive agents. We evaluated the efficacy and safety of an interferon-free regimen of the nucleotide polymerase inhibitor sofosbuvir combined with ribavirin for 24 weeks in treating post-transplantation HCV infection. In a prospective, multicenter, open-label pilot study, we enrolled patients with compensated recurrent HCV infection of any genotype after a primary or secondary liver transplantation. All patients received 24 weeks of sofosbuvir 400 mg daily and ribavirin starting at 400 mg daily, which was adjusted according to creatinine clearance and hemoglobin values. The primary end point was sustained virologic response 12 weeks after treatment. Of the 40 patients enrolled and treated, 78% were male, 85% were white, 83% had HCV genotype 1, 40% had cirrhosis (based on biopsy), and 88% had been previously treated with interferon. Sustained virologic response 12 weeks after treatment was achieved by 28 of 40 patients (70%; 90% confidence interval: 56%-82%). Relapse accounted for all cases of virologic failure. No patients had detectable viral resistance during or after treatment. The most common adverse events were fatigue (30%), diarrhea (28%), and headache (25%). In addition, 20% of the subjects experienced anemia. Two patients discontinued study treatment because of adverse events, which were considered unrelated to study treatment. No deaths, graft losses, or episodes of rejection occurred. No interactions with any concomitant immunosuppressive agents were reported. Sofosbuvir and ribavirin combination therapy for 24 weeks is an effective and well-tolerated interferon-free treatment for post-transplantation HCV infection. EudraCT, Number: 2012-002417-19; ClinicalTrials.gov, Number: NCT01687270.

Poor Outcomes After Liver Transplantation in Patients With Incidental Cholangiocarcinoma Irrespective of Tumor Localization

IntroductionAfter liver transplantation for cholangiocarcinoma (CCC), patients have a poor prognosis without use of specific therapeutic strategies. Accordingly, recipients with incidental CCC might have the highest risk of recurrent disease; however, sparse data on the long-term outcome of unselected patients with incidental CCC have been published. The aim of this study was to evaluate the post-transplantation outcomes of patients with incidental CCC with special focus on tumor localization. Material and MethodsThere were 11 primary liver transplantations in patients with incidental CCC of 1310 liver transplantation procedures performed between December 1994 and August 2013. All patients with incidental CCC received a chemotherapy regiment including gemcitabine/5 fluorouracil, doxorubicin, and mitomycin. The patients were switched from calcineurin inhibitors to mammalian target of rapamycin inhibitor−based immunosuppression shortly after CCC diagnosis. ResultsIntra- and extrahepatic tumors were found in 6 and 5 patients, respectively. At median follow-up examination of 26.3 months there were 8 CCC recurrences and 7 patient deaths. Overall survival after liver transplantation for incidental CCC was 88.9% at 1 year, 44.4% at 2 years, and 14.8% at 3 years. The corresponding rates of recurrence-free survival were 45.7%, 45.7%, and 0.0%, respectively. Post-transplantation CCC recurrences were universal with 0% 3-year recurrence-free survival both in patients with intra- and extrahepatic tumors (P = .475). ConclusionsIncidental CCC in liver transplantation is associated with poor outcomes irrespective of tumor localization. Introduction of new adjuvant multimodal treatment concepts is necessary to improve the prognosis for this subgroup of patients.

Outcomes Following Liver Transplantation for Metastatic Neuroendocrine Tumors

IntroductionMetastatic disease is generally considered as an absolute contraindication for liver transplantation. However, due to relatively low aggressiveness and slow progression rates, liver metastases from neuroendocrine tumors (NETs) form an exception to this rule. Given the scarcity of available data, the purpose of this study was to evaluate long-term outcomes following liver transplantation for NET metastases. Material and MethodsThere were 12 primary liver transplantations in patients with NET metastases out of 1334 liver transplantations performed in the Department of General, Transplant and Liver Surgery (Medical University of Warsaw) in the period between December 1989 and October 2013. Overall survival (OS) and disease-free survival (DFS) were set as primary and secondary outcome measures, respectively. ResultsMedian follow-up was 7.9 years. For all patients, OS rate was 78.6% at 10 years and DFS rate was 15.5% at 9 years. Intraoperative transfusions of packed red blood cells (P = .021), Ki-67 proliferative index more than 2% (P = .048), and grade 2 tumors (P = .037) were identified as factors significantly associated with worse DFS. Notably, loss of E-cadherin expression (P = .444), mitotic rate (P = .771), extent of liver involvement (P = .548), primary tumor site (P = .983), and recipient age (P = .425) were not significantly associated with DFS. ConclusionsExcellent long-term OS rates support liver transplantation for unresectable NET metastases despite almost universal post-transplantation tumor recurrence. Selection of patients with G1 tumors with Ki-67 index not exceeding 2% and reducing the requirement for intraoperative blood transfusions might improve DFS rates.

Incidence and risk factors of incisional hernia formation following abdominal organ transplantation.

Hernia formation is common following abdominal operations, and transplant patients are at increased risk due to postoperative immunosuppression. The purpose of this study was to estimate the incidence of incisional hernia formation following primary abdominal solid organ transplantation and identify clinical risk factors for hernia formation. We performed a single-institution retrospective review of a prospectively collected database to evaluate all patients who underwent primary liver, kidney, or pancreas transplantation between 2000 and 2011. The primary outcome was hernia formation at the transplant incision. Univariate and multivariate Cox proportional hazards models were used to identify risk factors for incisional hernia formation. A total of 3,460 transplants were performed during the study period: 2,247 kidney only, 718 liver only, and 495 pancreas or simultaneous pancreas and kidney (pancreas group). The overall incisional hernia rate was 7.5 %. The Kaplan-Meier rates of hernia formation at 1, 5, and 10 years were 2.5, 4.9, and 7.0 % for kidney; 4.5, 13.6, and 19.0 % for liver; and 2.5, 12.7, and 21.8 % for the pancreas groups. On univariate analysis, surgical site infection (SSI), body mass index (BMI) >25, delayed graft function, and withholding a calcineurin inhibitor or mycophenolate mofetil (MMF) were associated with hernia formation in the kidney group. SSI and BMI >25 were associated with hernia formation in the liver group. In the pancreas group, SSI, cyclosporine, and withholding MMF were all associated with hernia formation. On multivariate analysis, SSI was strongly associated with hernia formation in all groups. Hazard ratio: kidney = 24.71 (13.00-46.97); liver = 12.0 (6.40-22.52); pancreas = 12.95 (2.78-60.29). Incisional hernias are common following abdominal organ transplant with nearly one in five patients developing an incisional hernia 5 years after liver or pancreas transplantation. Strategies focusing on prevention and early treatment of SSI may help to decrease the risk of incisional hernia formation following abdominal organ transplantation.

Outcomes of adult liver re-transplant patients in the model for end-stage liver disease era: is it time to reconsider its indications?

To better understand the outcomes and utility of liver re-transplantation in non-hepatitis C patients, we sought to identify predictors that impact post-transplant patient and graft survival comparing primary liver transplant patients to those receiving subsequent allografts. We conducted a retrospective cohort analysis using the United Network for Organ Sharing database from February 2002 through December 2012, including non-hepatitis C infected adults (18yr and older) who underwent primary and repeat liver transplantation. Patient and graft survival were compared between the two groups using the Kaplan-Meier estimator. Cox proportional hazards models were constructed to evaluate variables associated with both patient and graft survival. We identified 33176 primary transplant recipients and 2710 re-transplants. Re-transplantation patients were more likely to be on dialysis prior to transplant (18% vs. 10%), hospitalized (26% vs. 16%), in the intensive care unit (ICU) (34% vs. 13%), on a ventilator (17% vs. 3%), and had higher model for end-stage liver disease (MELD) score (27 vs. 21). Re-transplants also received livers with a lower donor risk index (DRI) (1.57 vs. 1.64). We estimated an adjusted hazard ratio (HR) of 1.7 for patient survival (95% CI: 1.56-1.84) and 1.61 (95% CI: 1.5-1.73) for graft survival. Liver re-transplantation in non-hepatitis C patients, although life saving, has significantly inferior patient and graft survival compared to primary liver transplantation. Higher quality grafts are used inefficiently in a sicker patient population, suggesting that a more optimal strategy may include restricting their use to patients who obtain a longer term benefit.

Analysis of the curative effect of ABO-incompatible liver transplantation in the treatment in patients with acute severe liver disease

To analyze and evaluate the clinical effect of ABO-incompatible liver transplantation in the treatment of acute severe liver disease. A retrospective clinical study was conducted. The clinical data of 4 136 patients undergoing orthotopic liver transplantation in Organ Transplantation Center of Tianjin First Center Hospital from September 1999 to December 2013 were analyzed. The criteria of patients enrolled were as following: model for end-stage liver disease (MELD) score ≥ 20, the donor's and recipient's blood types were different, age 18-70 years, and undergone primary non-bypass orthotopic liver transplantation. According to the rate of compliance with the principles of blood transfusion, the cases were divided into two groups: ABO-compatible group (ABO-C group, n=41), ABO-incompatible group (ABO-I group, n=22). The patients in ABO-I group received basiliximab + methylprednisolone for immune induction therapy during operation, basiliximab + tacrolimus + mycophenolate + cortisol as quadruple immunosuppressive regimen after operation. They also received subcutaneous injection of low molecular heparin for anticoagulant therapy after operation, and oral warfarin or aspirin and clopidogrel bisulfate instead after 7 days. They also received routine alprostadil after operation. The remaining treatment was the same as that of ABO-C group. The clinical data, postoperative complications, rejection and survival rates of two groups were statistically analyzed. There were no significant differences in gender, age, MELD score, complicated with tumor, quality of donor liver, length of cold preservation of donor liver, duration of operation, and blood loss during operation between ABO-C and ABO-I groups. Number of splenectomy during operation was significantly higher in ABO-I group than that in ABO-C group (5 cases vs. 1 case, χ² = 4.687, P=0.030). The 3-month, 6-month, 1-year, 3-year and 5-year survival rates of ABO-C group were 89.5%, 78.3%, 72.5%, 69.1% and 61.8%, respectively, while those of ABO-I group were 78.9%, 72.9%, 65.6%, 56.2% and 46.8%, respectively. There was no significant difference in the cumulative survival rate between two groups (Log Rank, χ² = 0.647, df=1, P=0.421). The postoperative infection rate in ABO-I group was significantly higher than that of ABO-C group [63.6% (14/22) vs. 31.7% (13/41), χ² = 5.960, P=0.015]. There were no significant difference in postoperative complications of biliary tract [22.7% (5/22) vs. 12.2% (5/41), χ² = 0.531, P=0.466], vascular complications [31.8% (7/22) vs. 12.2% (5/41), χ² = 2.416, P=0.120], or rejection as diagnosed by pathology [22.7% (5/22) vs. 9.8% (4/41), χ² = 1.051, P=0.305] between ABO-I and ABO-C groups. Although ABO-incompatible liver transplantation was followed by higher postoperative infection rate and perioperative mortality, ABO-incompatible liver transplantation can still be used to save the patient with acute severe liver disease as there is a shortage of compatible donor at present.

Developments in pediatric liver transplantation since implementation of the new allocation rules in Eurotransplant.

Liver allocation in the Eurotransplant (ET) region has changed from a waiting time to an urgency-based system using the model of end-stage liver disease (MELD) score in 2006. To allow timely transplantation, pediatric recipients are allocated by an assigned pediatric MELD independent of severity of illness. Consequences for children listed at our center were evaluated by retrospective analysis of all primary pediatric liver transplantation (LTX) from deceased donors between 2002 and 2010 (110 LTX before/50 LTX after new allocation). Of 50 children transplanted in the MELD era, 17 (34%) underwent LTX with a high-urgent status that was real in five patients (median lab MELD 22, waiting time fived) and assigned in 12 patients (lab MELD 7, waiting time 35d). Thirty-three children received a liver by their assigned pediatric MELD (lab MELD 15, waiting time 255d). Waiting time in the two periods was similar, whereas the wait-list mortality decreased (from about four children/yr to about one child/yr). One- and three-yr patient survival showed no significant difference (94.5/97.7%; p=0.385) as did one- and three-yr graft survival (80.7/75.2%; and 86.5/82%; p=0.436 before/after). Introduction of a MELD-based allocation system in ET with assignment of a granted score for pediatric recipients has led to a clear priorization of children resulting in a low wait-list mortality and good clinical outcome.

Risk factors and surgical management of anastomotic biliary complications after pediatric liver transplantation.

Biliary complications (BCs) still remain the Achilles heel of liver transplantation (LT) with an overall incidence of 10% to 35% in pediatric series. We hypothesized that (1) the use of alternative techniques (reduced size, split, and living donor grafts) in pediatric LT may contribute to an increased incidence of BCs, and (2) surgery as a first treatment option for anastomotic BCs could allow a definitive cure for the majority of these patients. Four hundred twenty-nine primary pediatric LT procedures, including 88, 91, 47, and 203 whole, reduced size, split, and living donor grafts, respectively, that were performed between July 1993 and November 2010 were retrospectively reviewed. Demographic and surgical variables were analyzed, and their respective impact on BCs was studied with univariate and multivariate analyses. The modalities of BC management were also reviewed. The 1- and 5-year patient survival rates were 94% and 90%, 89% and 85%, 94% and 89%, and 98% and 94% for whole, reduced size, split, and living donor liver grafts, respectively. The overall incidence of BCs was 23% (n = 98). Sixty were anastomotic complications [47 strictures (78%) and 13 fistulas (22%)]. The graft type was not found to be an independent risk factor for the development of BCs. According to a multivariate analysis, only hepatic artery thrombosis and acute rejection increased the risk of anastomotic BCs (P < 0.001 and P = 0.003, respectively). Anastomotic BCs were managed primarily with surgical repair in 59 of 60 cases with a primary patency rate of 80% (n = 47). These results suggest that (1) most of the BCs were anastomotic complications not influenced by the type of graft, and (2) the surgical management of anastomotic BCs may constitute the first and best therapeutic option.

Reoperative Complications after Primary Orthotopic Liver Transplantation: A Contemporary Single-Center Experience in the Post–Model for End-Stage Liver Disease Era

Data on complications requiring reoperation after orthotopic liver transplantation (OLT) are limited. We sought to describe the spectrum of reoperative complications after OLT, evaluate the associations with graft and patient survival, and identify predictors of need for reoperation. We retrospectively studied adult patients who underwent primary OLT at our institution from February 2002 to July 2012. The primary outcomes included occurrence of a reoperative complication. Secondary outcomes were graft and patient survival. Multivariable logistic regression analysis was used to model the associations of recipient, donor, and operative variables with reoperation. Of 1,620 patients, 470 (29%) had complications requiring reoperation. The most common reoperative complication was bleeding (17.3%). Compared with patients not requiring reoperation, patients with reoperative complications had greater Model for End-Stage Liver Disease scores and need for pretransplantation hospitalization, mechanical ventilation, vasopressors, and renal replacement therapy; considerably longer cold and warm ischemia times and greater intraoperative blood transfusion requirements; and substantially worse 1-, 3-, and 5-year graft and patient survival rates. In multivariable analysis, predictors of reoperative complications included intraoperative transfusion of packed RBCs (odds ratio [OR]= 2.21; 95% CI, 1.91-2.56), donor length of hospitalization >8 days (OR= 1.87; 95% CI, 1.28-2.73), recipient pretransplantation mechanical ventilation (OR= 1.65; 95% CI, 1.21-2.24), cold ischemia time >9 hours (OR= 1.63; 95% CI, 1.23-2.17), warm ischemia time >55 minutes (OR= 1.58; 95% CI, 1.02-2.44), earlier major abdominal surgery (OR= 1.41; 95% CI, 1.03-1.92), and elevated donor serum sodium (OR= 1.17; 95% CI, 1.03-1.31). Patients who require reoperation for complications after OLT have high pretransplantation acuity and inferior post-transplantation survival. We identified factors associated with reoperative complications to guide perioperative donor-recipient matching and improve outcomes.

Causes of Death in Liver Transplant Candidates With MELD 10-22.

Background: Liver transplant (LT) candidates listed with a low MELD score have a relatively low predicted risk of 90-day mortality and are, therefore, at risk for dying of NON-liver related causes. As UNOS data lacks sufficient granularity, little is known of the specific causes of death in these patients. Methods: To investigate the true cause of death among LT candidates with a low MELD score, we identified all adults listed for primary LT at a single center listed with a laboratory MELD between 10-22 and without MELD exception points, who died during 2010-2012. Causes of death for these patients were identified from an electronic medical record review. Results: 126 wait-list candidates died during the study period. Of those who died, 80 patients met study inclusion criteria. Median age was 59 years [IQR 52-63], 63% were male, and 39% had hepatitis C. Median list MELD was 16 [IQR 13-18] and wait-list time was 15 months [IQR 7-33]. The median MELD score before the time of death was 34 [IQR 26-41]. A cause of death was identified in a total of 50 patients: 45 (90%) of whom died of complications related to end-stage liver disease (ESLD). Specific causes of death are shown in Figure. Three (7%) patients required urgent surgery and subsequently died from decompensated liver disease. In the 5 patients in whom death was determined to be non-liver related, the cause of death was pulmonary embolus (n=1), transfusion-related acute lung injury (n=1), or cardiac arrest (n=3) (Figure).Figure: No Caption available.Conclusion: The majority of liver transplant candidates listed with a laboratory MELD 10-22 who ultimately die remain on the list for nearly 2 years prior to their death. Rates of death from non-liver related causes are low. These data should compel patients with low MELD to pursue live-donor liver transplantation to reduce wait times and the risk of waitlist mortality.

Liver Transplantation Using Pediatric Organ Donation After Circulatory Death - An Analysis of the National Registry.

Background Organ scarcity has resulted in increased utilization of donation after cardiac death donors (DCD). There is limited national experience in using pediatric DCD organs in liver transplant(LT). Aim To compare the outcomes of patients who received pediatric DCD versus non-DCD livers, and to compare this to adult DCD donors to better understand survival outcomes after LT. Methods Between 2000-2012, 11975 patients who received primary LT were identified from the Scientific Registry of Transplant Recipients database(SRTR).Based on DCD status and donor age, patients divided into 4 groups; Group1:DCD donors <12 years (n= 97,55% male), Group2:DCD donors 13-17 years(n=216,68%male), Group3:DCD donors 18+years(n=2179,68% male) and Group 4:non-DCD donors 0-17 years (n=9483,63 male). The pediatric DCD and DBD mean age was, 13.1(sd=4.3) and 10.2(sd=6.2). The median follow up 36 months. We evaluated the graft and patient survival based on these groups using Kaplan-Meier models and multivariable Cox models. Results One-and five-year patient survivals were in Group1: 83% and 73%,Group2: 90% and 79%,Group3:83% and 67%,Group4: 88%and79%. In the multivariate model adjusted for recipient age,MELD/PELD and year of LT, young pediatric DCDs(Group1) had similar hazard for death relative to adult DCD donors(AHR=0.83, 95% C.I.0.54-1.29). However, older pediatric DCDs(Group2) conferred significantly lower risk(AHR=0.54,95%C.I.0.39-0.76) as did pediatric non DCD donors.The adjusted results for graft survival were similar among groups. Pediatric DCD allocation to adult recipients significantly varied by group:Group1 70%, Group2 98%, Group3 99% and Group4 51%. Conclusions Young pediatric-DCD donors are associated with similar outcomes as adult DCD donors. DCD donors aged 13-17 years are associated with superior outcomes than adult DCD donors and comparable with pediatric non DCD donors. Surgeons should not hesitate to use pediatric DCD donors in LT.Figure: No Caption available.the survival among the groups

Graft and Viral Outcomes in Retransplantation For HCV Recurrence and HCV Primary Liver Transplantation: A Case Control Study.

Graft and Viral Outcomes in Retransplantation For HCV Recurrence and HCV Primary Liver Transplantation: A Case Control Study.