Preoperative factors associated with outcome and their impact on resource use in 1148 consecutive primary liver transplants

Impact of the etiology of acute kidney injury on outcomes following liver transplantation: acute tubular necrosis versus hepatorenal syndrome

Acute kidney injury (AKI) at the time of liver transplantation (LT) has been associated with increased morbidity and mortality. In patients with potentially reversible renal dysfunction, predicting whether there will be sufficient return of native kidney function is sometimes difficult. Previous studies have focused mainly on the effect of the severity of renal dysfunction or the duration of pretransplant dialysis on posttransplant outcomes. We performed a retrospective analysis of patients who underwent LT at our center after Model for End-Stage Liver Disease-based allocation so that we could determine the impact of the etiology of AKI [acute tubular necrosis (ATN) versus hepatorenal syndrome (HRS)] on post-LT outcomes. The patients were stratified according to the severity of AKI at the time of LT as described by the Risk, Injury, Failure, Loss, and End-Stage Kidney Disease (RIFLE) classification: risk, injury, or failure. The RIFLE failure group was further subdivided according to the etiology of AKI: HRS or ATN. The patient survival and renal outcomes 1 and 5 years after LT were significantly worse for those with ATN. At 5 years, the incidence of chronic kidney disease (stage 4 or 5) was statistically higher in the ATN group versus the HRS group (56% versus 16%, P < 0.001). A multivariate analysis revealed that the presence of ATN at the time of LT was the only variable associated with higher mortality 1 year after LT (P < 0.001). Our study is the first to demonstrate that the etiology of AKI has the greatest impact on patient and renal outcomes after LT.

Prognostic value of standard parameters as predictors for long-term renal replacement therapy after liver transplantation

Chronic kidney disease has become increasingly prevalent after liver transplantation (LTPL) because outcome and survival rates have improved. Chronic kidney insufficiency is most likely associated with increased morbidity and mortality. The challenge is to identify patients who will be in need of long-term renal replacement therapy (RRT) after LTPL. We analyzed 208 liver transplant recipients with respect to mortality, associated laboratory values, underlying liver disease, immunosuppressive protocol and the need for RRT. Long-term RRT was defined by the need for RRT 3 months after LTPL. Altogether, 5.8% of the surviving study patients remained in need of RRT 3 months after LTPL. All of these patients continued to need RRT throughout the study period (2 years). The need for RRT significantly increased the 2-year mortality rate 4.3-fold, from 15.4 to 66.7% (p = 0.004). Comparison of laboratory and clinical parameters at the time of LTPL revealed no significant differences for creatinine, albumin and MDRD between patients undergoing hemodialysis 3 months after LTPL and patients without RRT. Comparing mean urea, a difference was observed. However, multivariate regression analyses using easy-to-observe demographic or laboratory parameters failed to generate a model to predict the need for RRT after LTPL. In addition, a comparison of underlying liver disease and immunosuppressive regimes identified no significant differences. Taken together, patients who were on hemodialysis 3 months after LTPL were also on hemodialysis 2 years after LTPL or until death. RRT 3 months after LTPL may predict the risk for chronic renal insufficiency and is associated with significantly increased mortality.

Oxygen persufflation as adjunct in liver preservation (OPAL): study protocol for a randomized controlled trial

BACKGROUND

Early graft dysfunction due to preservation/reperfusion injury represents a dramatic event after liver transplantation. Enhancement of donor organ criteria, in order to cope with the ever increasing donor shortage, further increases graft susceptibility to ischemic alterations. Major parts of post-preservation injury, however, occur at the time of warm reperfusion but not during ischemic storage; successful reperfusion of ischemic tissue in turn depends on an adequate redox and intracellular signal homeostasis. The latter has been shown experimentally to be favorably influenced by oxygen persufflation within short time spans. Thus viability of marginally preserved liver grafts could still be augmented by transient hypothermic reconditioning even after normal procurement and static cold storage. The present study is aimed to confirm the conceptual expectations, that hypothermic reconditioning by gaseous oxygen persufflation is a useful method to suppress injurious cellular activation cascades and to improve post-ischemic recovery of marginally preserved liver grafts.

METHODS/DESIGN

OPAL is a prospective single center randomized proof of concept study, including two parallel groups in a total of 116 liver transplant patients. The effect of an in hospital treatment of the isolated liver graft by 2 hours of oxygen persufflation immediately prior to transplantation will be assesses as compared to standard procedure (cold storage without further intervention). The primary endpoint is the peak transaminase serum level (AST) during the first three days after transplantation as a surrogate readout for parenchymal liver injury. Other outcomes comprise patient and graft survival, time of intensive care requirement, hepatic tissue perfusion 1h after revascularisation, early onset of graft dysfunction based on coagulation parameters, as well as the use of a refined scoring-system for initial graft function based on a multi-parameter (AST, ALT, Quick and bilirubin) score. Furthermore, the effect of OPAL on molecular pathways of autophagy and inflammatory cell activation will be evaluated. Final analysis will be based on all participants as randomized (intention to treat).

TRIAL REGISTRATION

Current Controlled Trials ISRCTN00167887.

Outcomes of orthotopic liver transplantation for hepatic sarcoidosis: an analysis of the United Network for Organ Sharing/Organ Procurement and Transplantation Network data files for a comparative study with cholestatic liver diseases

Hepatic sarcoidosis is a rare indication for liver transplantation. Using the United Network for Organ Sharing (UNOS)/Organ Procurement and Transplantation Network (OPTN) database, we evaluated patient and graft survival after orthotopic liver transplantation for sarcoidosis between October 1987 and December 2007. We assessed the potential prognostic value of multiple demographic and clinical variables, and we also compared these patients to a case-matched group of patients with primary sclerosing cholangitis (PSC) or primary biliary cirrhosis (PBC). The 1- and 5-year survival rates for the sarcoidosis group were 78% and 61%, respectively, and these rates were significantly worse than the rates for the PSC/PBC group (P = 0.001). Disease recurrence in the liver is a rare cause of graft loss or patient death. Three deaths occurred in the sarcoidosis group because of recurrent hepatic sarcoidosis, and 1 death was a result of cardiac sarcoidosis. A univariate analysis identified an increasing donor risk index as a significant negative factor for outcomes for the sarcoidosis group [hazard ratio (HR) = 2.06, confidence interval (CI) = 1.04-4.06, P = 0.037], but this finding was not found in a multivariate analysis, in which no independent predictors were found to have a significant impact. A case-matched univariate analysis demonstrated that sarcoidosis and morbid obesity were significant negative factors for outcomes, and in a multivariate analysis, sarcoidosis continued to predict worse outcomes (HR = 2.39, CI = 1.21-4.73, P = 0.012). In conclusion, an analysis of the UNOS/OPTN database indicates that the patient and allograft survival rates for hepatic sarcoidosis are satisfactory, but they are worse in comparison with the rates for other cholestatic liver diseases.

Liver transplantation in the 21st century: expanding the donor options

Over the past decade, use of ECD organs for OLT has allowed many transplant programs to afford patients access to an otherwise scarce resource and to maintain center volume. Although overall posttransplant outcomes are inferior to results with optimal, whole-liver grafts, aggressive utilization of ECD and DCD organs significantly lowers median wait-times for OLT, MELD score at OLT, and death while awaiting transplantation. It is incumbent on the transplant community to provide continued scrutiny of the many factors involved in ECD organ utilization, evaluate the degree of risk and benefit such allografts may impart on particular recipients, and thereby provide suitable “matching” to maximize favorable outcomes. Transplant caregivers need to provide patients with evidence-based care decisions, be good stewards of a scarce resource, and maintain threshold survival results for their programs. This requires balancing the urgency with which a transplant is needed and the utility of such a transplant. There is a clear necessity to pursue additional donor research to improve use of these marginal grafts and assess interventions that enhance the safety of ECD livers.

LabMELD-based organ allocation increases total costs of liver transplantation: a single-center experience

INTRODUCTION

In 2006, model for end-stage liver disease (MELD)-based allocation was implemented in the Eurotransplant (ET) region. Sick patients, who in general require more resources, are prioritized. In this analysis, the effect of MELD on costs for liver transplantation (LTx) was assessed.

METHODS

Total costs for LTx before and after implementation of MELD were identified in 256 patients from January 2005-December 2007. Forty-nine patients (Re-LTx, HU listings, and 30-d mortality) were excluded from further analysis. The costs of LTx in 207 patients have been correlated with their corresponding labMELD; 84 and 123 LTx before and after implementation of MELD were compared, and patient survival was monitored.

RESULTS

A positive correlation exists between labMELD and costs (r(2) = 0.28; p < 0.05). Only nominal correlation existed between the Child-Pugh classification and costs. The labMELD scores can be stratified into four groups (I: 6-10, II: 11-18, III: 19-24, and IV: >24), with an increase of €15.672 ± 2.233 between each group (p < 0.05). Recipients' labMELD at the time of LTx increased significantly in the MELD-based allocation system. Costs increased by €11.650/patient (p < 0.05), while median survival decreased from 1219 to 869 d (p < 0.05).

CONCLUSION

LabMELD-based allocation increased total costs of LTx. In accordance with other studies, the sickest patients need the most resources.

Basiliximab induction and delayed calcineurin inhibitor initiation in liver transplant recipients with renal insufficiency

BACKGROUND

Renal insufficiency (RI) is common after liver transplantation (LT) and may worsen due to calcineurin inhibitor (CNI) use. We compared LT outcomes using basiliximab induction and delayed CNI initiation to controls with a standard CNI regimen in patients with peri-LT RI.

METHODS

All adults transplanted January 2004 to December 2007 with peri-LT RI (hemodialysis or creatinine ≥1.5 within 1 week of LT) were included in a retrospective nonrandomized cohort. Outcomes including 30-day and 1-year patient and graft survival and renal function were compared between basiliximab and control groups.

RESULTS

Two hundred twenty-nine patients (102 basiliximab, 127 controls) were analyzed, mean age 54 years, 72% men, 54% with hepatitis C virus. Mean model for end-stage liver disease (28.2 vs. 20.0; P<0.001) and creatinine (1.9 vs. 1.6; P=0.001) were higher and more patients were on hemodialysis at LT (29% vs. 6%; P<0.001) in the basiliximab group. 30-day patient (99% vs. 97%; P=0.26) and graft survival (98% vs. 95%; P=0.17), 1-year patient (87% vs. 87%; P=0.89) and graft survival (86% vs. 82%; P=0.37), mean creatinine at 1-year (1.5 vs. 1.5 mg/dL; P=0.82), and treated acute rejection (6% vs. 6%; P=0.90) were similar between basiliximab and control groups, respectively. In multivariable logistic regression, basiliximab was not significantly associated with 30-day (odds ratio, 0.10; P=0.11) or 1-year (odds ratio, 0.97; P=0.94) survival, controlling for age, previous LT, model for end-stage liver disease, and hepatitis C virus.

CONCLUSIONS

Basiliximab induction resulted in 30-day and 1-year patient, graft and renal outcomes comparable with a control group receiving standard CNI-based immunosuppression. Antibody induction with delayed CNI should be further studied prospectively.

Predictors of patient survival following living donor liver transplantation

BACKGROUND

Living donor liver transplantation (LDLT) is considered to be the alterative choice in light of the great shortage of cadaveric donors. However, the characteristics of the patients who will benefit from LDLT have not been well identified. The aim of this study was to define the pre- and intra-operative factors that may influence patient outcome.

METHODS

The data from 102 LDLT patients who had operations between 2002 and 2009 were collected and analyzed retrospectively. Data were analyzed using uni- and multi-variate analysis according to factors that are known to be associated with outcome in these patients.

RESULTS

Overall, the accurate survival rate of recipients at 1, 3, and 5 years was 84%, 76%, and 70%, respectively. The independent risk factors, preoperative renal dysfunction, intraoperative red blood cell transfusions of greater than 5 units, and female to male match (donor to recipient matching), were identified by Cox regression analysis. The pre-transplant model for end-stage liver disease score and a graft to recipient weight ratio of less than 0.8% were not predictive of outcome. The overall 1-, 3-, and 5-year survival of patients with one or no risk factors and two or more risk factors were 91%, 86%, and 83% and 67%, 56%, and 47%, respectively (P<0.0001).

CONCLUSIONS

In our retrospective study, preoperative renal dysfunction, intraoperative red blood cell transfusions of greater than 5 units, and female to male gender match were independent risk factors for LDLT recipient outcome. Two or more of these risk factors may contribute to poor outcome.

Surgical aspects and outcome of combined liver and kidney transplantation in children

In children with renal insufficiency and accompanying or underlying liver disease, combined liver and kidney transplantations (CLKT) are indicated. However, because of the rare indications, the number of paediatric CLKT is low. Our aim was to analyse CLKT in children with special regard to surgical aspects and outcome. All paediatric CLKT performed at our institution between 1998 and 2009 were retrospectively analysed. Between 1998 and 2009, 15 CLKT were performed in 14 paediatric patients (median age 8 years, range 1-16 years). The indications for CLKT were autosomal recessive polycystic kidney disease (n = 7), primary hyperoxaluria type 1 (n = 7) and retransplantation because of primary liver nonfunction (n = 1). In the postoperative course, six patients showed bleeding complications, thereof three patients needed operative revision for intra-abdominal bleeding. Eight of 15 patients (53%) needed dialysis. The 1- and 5-year patient survival was 100%; and 1- and 5-year graft survival was 80% for the liver and 93% for the kidney allograft. A number of different complications, especially secondary haemorrhage have to be anticipated after CLKT, requiring a timely and interdisciplinary treatment approach. With this management, our patients showed an excellent graft and patient survival.

Increased model for end-stage liver disease score at the time of liver transplant results in prolonged hospitalization and overall intensive care unit costs

Organ allocation based on Model for End-Stage Liver Disease (MELD) resulted in decreased waiting list mortality in the United States. However, reports suggest an increase in resource utilization as a consequence of this. The aim of this study is to assess the correlation of MELD at transplant with post-liver transplant (LT) intensive care unit (ICU) costs. We assessed clinical and demographic variables of 402 adult patients who underwent LT at King's College Hospital, London, UK, between January 2000 and December 2003. ICU cost calculations were based on the therapeutic intervention scoring system (TISS). Graft quality was assessed using the donor risk index (DRI). Patients with a MELD score > 24 had significantly longer post-LT ICU stay (P < 0.0001) and total post-LT hospital stay (P = 0.008). In addition, they had significantly increased TISS scores, ICU cost, and need for renal replacement therapy (RRT) (P < 0.001). MELD score (by point) and MELD > 24 was associated with prolonged ICU stay (P = 0.004 and P = 0.005, respectively). On univariate analysis, etiology of alcohol-related liver disease (ALD), repeat LT, Budd-Chiari syndrome, and refractory ascites were associated with prolonged ICU stay. Using multivariate analysis, MELD > 24, refractory ascites, ALD and Budd-Chiari syndrome were associated with prolonged ICU stay. There was no association between using grafts with higher DRI and longer ICU stay, need for RRT, increased cost, or hospital survival on univariate analyses (P = not significant). Use of MELD as a method of organ allocation results in significant increase in ICU cost after LT. Using TISS as surrogate marker for ICU costs reveals that the cost implications are related to the need for RRT and prolonged ICU stay.

Comparative prospective study of two liver graft preservation solutions: University of Wisconsin and Celsior

University of Wisconsin solution (UWS) is the gold standard for graft preservation. Celsior solution (CS) is a new solution not as yet widely used in liver grafts. The aim of this study was to compare the liver function of transplanted grafts stored in these 2 preservation solutions. The primary endpoints were the rates of primary nonfunction (PNF) and primary dysfunction (PDF). We performed a prospective and pseudorandomized study that included 196 patients (representing 104 and 92 livers preserved in UWS and CS, respectively) at La Fe University Hospital (Valencia, Spain) between March 2003 and May 2005. PNF and PDF rates, liver function laboratory parameters, postoperative bleeding, vascular and biliary complications, and patient and graft survival at 3 years were compared for the 2 groups. The 2 groups were similar in terms of donor variables, recipient variables, and surgical techniques. The PNF rates were 2.2% and 1.9% in the CS and UWS groups, respectively (P = not significant), and the PDF rates were 15.2% and 15.5% in the CS and UWS groups, respectively (P = not significant). There were no significant differences in the laboratory parameters for the 2 groups, except for alanine aminotransferase levels in month 3, which were lower in the CS group (P = 0.01). No significant differences were observed in terms of complications. Three-year patient and graft survival rates were as follows for years 1, 2, and 3: 83%, 80%, and 76% (patient) and 80%, 77%, and 73% (graft) for the UWS group and 83%, 77%, and 70% (patient) and 81%, 73%, and 67% (graft) for the CS group (P = not significant). In conclusion, this study shows that CS is as effective as UWS in liver preservation.

Factors influencing liver transplant length of stay at two large-volume transplant centers

Length of stay (LOS) is considered a reliable surrogate for liver transplant resource utilization. Little information exists about how donor and recipient variables interact to affect transplant LOS. Data for adult, non-status 1 transplants (1998-2005), including the donor risk index (DRI) and Model for End-Stage Liver Disease (MELD) scores, were collected from 2 institutions (n = 745 for center A and n = 710 for center B). Cox proportional hazards models identified variables associated with LOS for the separate and combined cohorts. The cohorts differed significantly in donor, recipient, and transplant factors. DRI (1.46 for center A and 1.40 for center B, P = 0.0013) and MELD (22.4 for center A and 20.4 for center B, P = 0.046) were both higher at center A, but LOS was comparable (13.7 days for center A and 13.3 days for center B, P = 0.052). Three factors at center A (nonlocal donor, recipient age, and MELD) and 7 factors at center B (donor age and weight, recipient female gender, retransplant status, international normalized ratio, MELD, and cold ischemia time) were associated with transplant LOS. For the combined cohort, donor age, weight, nonlocal status, recipient age, female gender, retransplant status, MELD, and transplant center were LOS risk factors. In conclusion, the impact of donor and recipient variables on LOS varies by institution. However, the MELD score exerts a potent and consistent effect across institutions, emphasizing the dominant role of disease severity in liver transplant resource utilization.

Brain death and its implications for management of the potential organ donor

The systemic physiologic changes that occur during and after brain death affect all organs suitable for transplantation. Major changes occur in the cardiovascular, pulmonary, endocrine, and immunological systems, and, if untreated may soon result in cardiovascular collapse and somatic death. Understanding these complex physiologic changes is mandatory for developing effective strategies for donor resuscitation and management in such a way that the functional integrity of potentially transplantable organs is maintained. This review elucidates these physiological changes and their consequences, and based on these consequences the rationale behind current medical management of brain-dead organ donors is discussed.

An early increase in gamma glutamyltranspeptidase and low aspartate aminotransferase peak values are associated with superior outcomes after orthotopic liver transplantation

BACKGROUND

Prediction of prognosis after liver transplantation (OLT) remains difficult. The present study determines if standard laboratory parameters measured within the first week after OLT correlate with outcome.

PATIENTS AND METHODS

Laboratory parameters measured within the first weak after OLT of 328 patients were grouped either graft loss or death within 90 days after (group 1: graft loss; group 2: death; group 3: neither graft loss nor death within 90 days).

RESULTS

Peak AST and ALT were significantly lower in group 3 (1867 and 1252 U/L) than in group 1 (4474 and 2077 U/L) or 2 (3121 and 1865 U/L). Bilirubin was significantly lower and gamma-GT significantly higher in group 3 compared to groups 1 and 2. In multivariate analysis, high AST peaks were independently associated with death or graft loss within 90 days. An increase in gamma-GT and low bilirubin early after transplantation were found to be independently associated with superior outcome.

DISCUSSION

Unexpectedly, a disproportionate rise in gamma-GT was associated with graft and patient survival of more than 90 days. This might be explained by regeneration phenomena in the liver indicative of a well functioning graft.

Outcome of combined liver and kidney transplantation in hepatitis C: a single-center long-term follow-up experience

INTRODUCTION

Hepatitis C (HCV) cirrhosis is the prevalent liver disease requiring liver transplantation in the United States. Candidates who also have end-stage renal disease, chronic renal disease stage 4, or prolonged hepatorenal syndrome are considered for combined liver and kidney transplantation (CLKT).

MATERIALS AND METHODS

We performed a retrospective study of HCV(+) and HCV(-) CLKT patients with more than 12 months of follow-up and HCV(+) patients with isolated liver transplant (OLT) to compare the outcomes of various groups.

RESULTS

Since 1988, 2983 OLTs were performed at our institution including 58 CLKTs. Of these, 23 were HCV(+) subjects who were significantly older than HCV(-) CLKT patients. Race, pretransplant dialysis time, renal indication for CLKT, Model for End-stage Liver Disease score, donor age, liver and kidney rejection as well as occurrence of posttransplant hypertension were similar among HCV(+) and HCV(-) CLKT patients. Posttransplant diabetes was observed in 80% of the HCV(+) group and 30% of the HCV(-) group (P = .01). Renal function seemed to be better in HCV(-) when compared with HCV(+) subjects at 5 years (P = .09). Overall patient survival for HCV(+) CLKT, HCV(-) CLKT, and HCV(+) OLT groups at 1, 2, and 5 years were not significantly different (P = .6).

CONCLUSION

HCV positivity should not exclude appropriate candidates for CLKT.

Indications for combined liver and kidney transplantation in children

A significant number of patients awaiting liver transplantation have associated renal failure and renal dysfunction is associated with increased morbidity and mortality after LT. There has been a recent increase in the number of CLKT in adults. The common indications for CLKT in children are different from those of adults and include metabolic diseases affecting the kidney with or without liver dysfunction and congenital developmental abnormalities affecting both organs. The results are generally encouraging among these groups of patients. Early evaluation and listing of patients before they become severely ill or have major systemic manifestations of their metabolic problem are important.

Donor risk index and MELD interactions in predicting long-term graft survival: a single-centre experience

INTRODUCTION

Feng et al. described the donor risk index (DRI) in North American liver transplant recipients. We evaluated the effect of the DRI and model for end-stage liver disease (MELD) score on liver transplant recipients from a single center in the United Kingdom.

METHOD

Prospectively, collected data of all patients transplanted at our center between January 1995 and December 2005 were included in the analysis (n=1090). Outcomes evaluated included patient-censored and death-censored graft survival. Outcomes of liver transplantation from "high" and "low" DRI groups (> or =1.8 and <1.8, respectively) on patients categorized into low (<15), intermediate (15-30), and high (>30) MELD categories were analyzed.

RESULTS

MELD at transplant was the only significant predictor of patient survival. MELD at transplant and DRI more than 1.7 were associated with a poorer graft survival (P=0.03). There was a trend toward poorer graft survival in high DRI grafts transplanted in low and "intermediate" MELD categories (P=0.47 and 0.006, respectively). However, in the high MELD category, there was a similar graft survival for both high and low DRI grafts.

CONCLUSION

Patients with low and intermediate MELDs at transplantation may be better served by a low DRI graft, whereas patients with high MELD may not be compromised by receiving a high DRI graft.

Surgical site infection after liver transplantation: risk factors and association with graft loss or death

BACKGROUND

Risk factors for surgical site infection (SSI) after liver transplantation and outcomes associated with these infections have not been assessed using consensus surveillance and optimal analytic methods.

METHODS

A cohort study was performed of patients undergoing first liver transplantation at Mayo Clinic, Jacksonville, Florida, in 2003 and 2004. SSIs were identified by definitions and methods of the National Nosocomial Infections Surveillance System. Measures of known or suspected risk factors for SSI, graft loss, or death were collected on all patients. Associations of SSI with these factors and also with the primary composite endpoint of graft loss or death within 1 year of liver transplantation were examined using Cox proportional hazards models; relative risks (RRs) were estimated along with 95% confidence intervals (CIs).

RESULTS

Of 370 patients, 66 (18%) had SSI and 57 (15%) died or sustained graft loss within 1 year after liver transplantation. Donor liver mass-to-recipient body mass ratio of less than 0.01 (RR 2.56; 95% CI 1.17-5.62; P=0.019) and increased operative time (RR 1.19 [1-hr increase]; 95% CI 1.03-1.37; P=0.018) were associated with increased SSI risk. SSI was associated with increased risk of death or graft loss within the first year after liver transplantation (RR 3.06; 95% CI 1.66-5.64; P<0.001).

CONCLUSION

SSI is associated with increased risk of death or graft loss during the first year after liver transplantation. Increased operative time and decreased donor liver-to-recipient body mass ratio showed evidence of association with SSI.

Current indications for combined liver and kidney transplantation in adults

A significant number of patients awaiting liver transplantation have associated renal failure. Combined Liver and Kidney Transplantation (CLKT) is increasingly offered especially since the introduction of Model for End-Stage Liver Disease (MELD). Decision to perform CLKT is straightforward when both organs suffer end-stage failure. However, the indications for CLKT are not well defined and there is controversy concerning some. We reviewed available data on PUBMED, United Network for Organ Sharing (UNOS), Organ Procurement Transplantation Network (OPTN), European Society for Organ Transplantation (ESOT) and discuss all current indications for CLKT.

CONCLUSION

Overall long-term outcome following CLKT is acceptable. There is an urgent need to further refine our ability to identify the cases with reversible renal injury in the setting of end-stage liver disease to avoid unnecessary CLKT. Liver protects the kidney from disease recurrence and allograft loss in metabolic diseases. However, the use of liver allograft for immunological protection of kidneys in highly sensitised patients with positive cross-match and previously failed renal transplants is still experimental.

Age-related decrease in proteasome expression contributes to defective nuclear factor-kappaB activation during hepatic ischemia/reperfusion

Hepatic ischemia/reperfusion (I/R) leads to liver injury and dysfunction through the initiation of a biphasic inflammatory response that is regulated by the transcription factor nuclear factor kappaB (NF-kappaB). We have previously shown that there is an age-dependent difference in the injury response to hepatic I/R in mice that correlates with divergent activation of NF-kappaB such that young mice have greater NF-kappaB activation, but less injury than old mice. In this study, we investigated the mechanism by which age alters the activation of NF-kappaB in the liver during I/R. Young (4-5 weeks) and old (12-14 months) mice underwent partial hepatic I/R. Livers were obtained for RNA microarray analysis and protein expression assays. Using microarray analysis, we identified age-dependent differences in the expression of genes related to protein ubiquitinylation and the proteasome. In old mice, genes that are involved in the ubiquitin-proteasome pathway were significantly down-regulated during I/R. Consistent with these findings, expression of a critical proteasome subunit, non-adenosine triphosphatase 4 (PSMD4), was reduced in old mice. Expression of the NF-kappaB inhibitory protein, IkappaB alpha, was increased in old mice and was greatly phosphorylated and ubiquitinylated. The data provide strong evidence that the age-related defect in hepatic NF-kappaB signaling during I/R is a result of decreased expression of PSMD4, a proteasome subunit responsible for recognition and recruitment of ubiquitinylated substrates to the proteasome. It appears that decreased PSMD4 expression prevents recruitment of phosphorylated and ubiquitinylated IkappaB alpha to the proteasome, resulting in a defect in NF-kappaB activation.

Expanding the Donor Pool for Liver Transplantation in the Setting of an “Opt-out” Scheme – 3 years after New Legislation

Introduction: The revised Human Organ Transplant Act (HOTA) was implemented in Singapore in July 2004. We aim to evaluate expanding the potential donor pool for liver transplant in Singapore with the inclusion of marginal donors. Materials and Methods: All donor referrals between July 2004 and June 2007 were studied. All potential deceased liver donors were heart-beating. After being reviewed by the transplant coordinator, potential donors were assessed by a transplant hepatologist and a transplant surgeon for suitability of organ donation strictly based on the programme’s donor assessment protocol. Reasons for rejection as potential donors were documented. The clinical characteristics of all donor referrals were retrospectively reviewed, and an independent decision was made as to whether liver retrieval in each rejected case might have been possible. Results: Among the 128 potential donor referrals, 20 donors (15.6%) underwent liver retrieval. Of the 20 livers retrieved, 16 were implanted and 4 were not implanted (3 unfit recipients, and 1 donor liver with 40% steatosis). Another 10 donor livers were assessed intraoperatively and were rejected because of varying levels of steatosis. Of these livers assessed, 5 donor livers had steatosis <40% and 5 had steatosis >40%. Of the remaining potential donors, 45 were deemed not possible because of prolonged hypotension (9), on-going or unresolved sepsis (13), high-risk behaviour (4), non-actualisation (8), or pre-existing medical conditions (11). Another 53 donors may potentially have been suitable donors but were rejected because of possible sepsis (13), no suitable recipients (12), transient hypotension (10), transient abnormal liver function test (6), history of alcohol ingestion (5), non-actualisation because of consent (4) and other reasons (3). Overall, it was deemed that 61 donors (47.7%) might potentially have been suitable liver donors. Conclusions: Despite new legislation (HOTA) in Singapore, the utilisation of cadaveric donor livers showed no increase in the last 3 years. By expanding our donor criteria to include marginal donors, we could potentially increase the availability of deceased donor livers to meet our waiting list demands. Key words: Liver transplant, Marginal livers, New legislation, Opt-out scheme

MELD and other predictors of survival after liver transplantation

BACKGROUND

This study examined how reliable is the pre-transplant model for end-stage liver disease (MELD) score in predicting post-transplantation survival and analyzed variables associated with patient survival.

METHODS

A cohort study was conducted. Receiver operating characteristic curve c-statistics were used to determine the ability of MELD score to predict mortality. The Kaplan-Meier (KM) method was used to analyze survival as a function of time regarding the MELD score and Child-Turcotte-Pugh (CTP) category. The Cox model was employed to assess the association between baseline risk factors and mortality.

RESULTS

Recipients and donors were mostly male, with a mean age of 51.6 and 38.5 yr, respectively (n = 436 transplants). The c-statistic values for three-month patient mortality were 0.60 and 0.61 for MELD score and CTP category, respectively. KM survival at three, six and 12 months were lower in those who had a MELD score > or =21 or were CTP category C. Multivariate analysis revealed that recipient age > or =65 yr, MELD > or = 21, CTP C category, bilirubin > or = 7 mg/dL, creatinine > or = 1.5 mg/dL, platelet transfusion, hepatocellular carcinoma, and non-white color donor skin were predictors of mortality.

CONCLUSIONS

Severe pre-transplant liver disease, age > or = 65, non-white skin donor, and hepatocellular carcinoma are associated with poor outcome.

Hepatic IL-8 release during graft procurement is associated with impaired graft function after human liver transplantation

In experimental models, brain death induces inflammatory cascades, leading to reduced graft survival. Thus far, factors prior to graft preservation have gained less attention in clinical setting. We studied pre-preservation inflammatory response and its effects on graft function in 30 brain dead liver donors and the respective recipients. Before donor graft perfusion, portal and hepatic venous blood samples were drawn for phagocyte adhesion molecule expression and plasma cytokine determinations. Donor intensive care unit stay correlated with donor C-reactive protein (R = 0.472, p = 0.013) and IL-6 (R = 0.419, p = 0.026) levels, and donor (R = 0.478, p = 0.016) and recipient gamma-glutamyl transferase (R = 0.432, p = 0.019) levels. During graft procurement, hepatic IL-8 release was observed in 17/30 donors. Grafts with hepatic IL-8 release exhibited subsequently higher alkaline phosphatase [319 (213-405) IU/L vs. 175 (149-208) IU/L, p = 0.006] and bilirubin [101 (44-139) micromol/L vs. 30 (23-72) micromol/L, p = 0.029] levels after transplantation. Our findings support the concept that inflammatory response in the brain dead organ donor contributes to the development of graft injury in human liver transplantation.

D-MELD, a simple predictor of post liver transplant mortality for optimization of donor/recipient matching

Numerous donor and recipient risk factors interact to influence the probability of survival after liver transplantation. We developed a statistic, D-MELD, the product of donor age and preoperative MELD, calculated from laboratory values. Using the UNOS STAR national transplant data base, we analyzed survival for first liver transplant recipients with chronic liver failure from deceased after brain death donors. Preoperative D-MELD score effectively stratified posttransplant survival. Using a cutoff D-MELD score of 1600, we defined a subgroup of donor-recipient matches with significantly poorer short- and long-term outcomes as measured by survival and length of stay (LOS). Avoidance of D-MELD scores above 1600 improved results for subgroups of high-risk patients with donor age >/=60 and those with preoperative MELD >/=30. D-MELD >/=1600 accurately predicted worse outcome in recipients with and without hepatitis C. There is significant regional variation in average D-MELD scores at transplant, however, regions with larger numbers of high D-MELD matches do not have higher survival rates. D-MELD is a simple, highly predictive tool for estimating outcomes after liver transplantation. This statistic could assist surgeons and their patients in making organ acceptance decisions. Applying D-MELD to liver allocation could eliminate many donor/recipient matches likely to have inferior outcome.

Hot topics in liver transplantation: organ allocation--extended criteria donor--living donor liver transplantation

Liver transplantation has become the mainstay for the treatment of end-stage liver disease, hepatocellular cancer and some metabolic disorders. Its main drawback, though, is the disparity between the number of donors and the patients needing a liver graft. In this review we will discuss the recent changes regarding organ allocation, extended donor criteria, living donor liver transplantation and potential room for improvement. The gap between the number of donors and patients needing a liver graft forced the transplant community to introduce an objective model such as the modified model for end-stage liver disease (MELD) in order to obtain a transparent and fair organ allocation system. The use of extended criteria donor livers such as organs from older donors or steatotic grafts is one possibility to reduce the gap between patients on the waiting list and available donors. Finally, living donor liver transplantation has become a standard procedure in specialized centers as another possibility to reduce the donor shortage. Recent data clearly indicate that center experience is of major importance in achieving good results. Great progress has been made in recent years. However, further research is needed to improve results in the future.

Activation of peroxisome proliferator-activated receptor-gamma during hepatic ischemia is age-dependent

Hepatic ischemia/reperfusion injury is a complication of liver surgery, transplantation, and shock and is known to be age-dependent. Our laboratory has recently shown that peroxisome proliferator-activated receptor-gamma (PPARgamma) is down-regulated during hepatic ischemia and that this exacerbates injury. Here we examined whether activation of PPARgamma during ischemia was age-dependent. Male mice of different ages (young: 4-5 weeks; adult: 10-12 weeks; old: 10-12 months) were subjected to up to 90 min of hepatic ischemia. PPARgamma activation occurred throughout ischemia in young mice, whereas activation in adult and old mice was lost after 30 min. No significant differences were noted in PPARgamma ligand expression among the age groups. However, in young mice we observed a predominance of PPARgamma1 in the nucleus, whereas in old mice this isoform remained largely in the cytoplasm. Finally, the degree of PPARgamma activation was associated with autophagy in the liver, a mechanism of self-preservation. PPARgamma activation is prolonged in young mice as compared to older mice. This appears to be mediated by a selective retention of PPARgamma1 in the nucleus and is associated with increased autophagy. The data suggest that PPARgamma activation is an important component of the age-dependent response to hepatic ischemia/reperfusion injury.

Transplantation: impact of pretransplant renal insufficiency

Pre-liver transplant renal dysfunction is associated with decreased survival following transplantation and is also a prognostic indicator of posttransplant chronic kidney disease. Selection of patients for combined liver/kidney transplantation versus orthotopic liver transplantation alone (OLTa) is often difficult given the lack of a reliable method to predict which patients will have ongoing severe renal dysfunction in the absence of concomitant kidney transplantation. We hypothesized that most patients with pretransplant renal dysfunction (serum creatinine > or = 1.5 mg/dL for at least 2 weeks prior to and at time of transplant) will not experience a rapid decline in estimated glomerular filtration rates (eGF) post-OLTa to the point of necessitating consideration for kidney transplantation, even in the setting of calcineurin inhibitor-based immunosuppression. We performed a single-center retrospective study of 60 OLTa patients with pretransplant renal dysfunction transplanted between 2000 and 2005. Kaplan-Meier analysis was performed of the time interval to develop eGFR < 20 mL/minute post-OLTa. At OLTa, the mean patient age was 59 years, and median serum creatinine was 1.8 mg/dL; 42% patients were hepatitis C-positive, 32% were diabetic, 38% had kidney dysfunction > 12 weeks, and 5% were receiving hemodialysis. After 36 months median follow-up post-OLTa, only 8 patients (13%) with significant renal dysfunction pre-OLTa achieved eGFR < 20 mL/minute. Patients with pretransplant kidney dysfunction > 12 weeks were at increased risk for eGFR < 20 mL/minute (hazard ratio = 5.3, P = 0.04), a risk that escalated after adjustment for age and serum creatinine at transplant (hazard ratio = 8.9, P = 0.01). Significant predictors of eGFR < 20 mL/minute post-OLTa in this patient cohort were the presence of diabetes and the serum creatinine level at transplant. In conclusion, few patients with preexisting renal dysfunction, especially if <12 weeks duration, experience a significant drop in eGFR post-OLTa.

Scientific basis of organ preservation

PURPOSE OF REVIEW

To review the basic mechanisms involved during hypothermia and reperfusion, with special attention paid to efforts being made in refining solutions and the molecular characterization of cells during preservation.

RECENT FINDINGS

Several graft-related molecules have been identified as correlating with early graft dysfunction and/or poor outcome in the immediate posttransplant period. Also, different inhibitors have been utilized to ameliorate the preservation-induced injury, alone or in combination with different preservation solutions.

SUMMARY

Preservation-induced injury is a major contributing factor to early graft dysfunction in organ recipients. The success of organ transplantation is critically dependent on the quality of the donor organ. Donor-organ quality, in turn, is determined by a variety of factors, including donor age, donor management prior to organ procurement, the duration of hypothermic storage, and perfusion techniques utilized to protect organs from ischemia/reperfusion injury, which in turn cause a dramatic reprogramming of cell metabolism during organ transplantation. The expression of a number of inflammatory genes has been associated with early graft dysfunction and/or poor outcome in the immediate postoperative period. Some therapeutic manipulations have been demonstrated to be of significance in attaining near-normal organ function after transplantation.

[Donors yesterday and today: have the characteristics of liver donors changed over the last 15 years?]

INTRODUCTION

The social, medical and demographic changes of our population and the increase in the number of patients on waiting lists have led to some changes in the selection criteria of organ donors.

MATERIAL AND METHOD

A retrospective, descriptive and comparative study of the liver cadaveric donors features accepted in the Liver Transplant Unit in La Fe University Hospital of Valencia (Spain) in 2 different periods. We distributed the cases into 2 groups, including in group A the first 200 first donors (from January 1991 to June 1995) and in group B the last 200 donors (from February 2004 to December 2005).

RESULTS

The number of donors increased from 18 during 1991 to 106 in 2006. In group A the mean age was 32.4 years, compared to 52.3 years in group B. In group A, the main cause of death was craneoencephalic traumatism and in group B cerebrovascular accidents. The mean time in the intensive care unit was longer in the second group with 67.2 hours. In group B, considerable atherosclerosis was reported in 17% of cadaveric donors and macroscopic liver steatosis in 29.5%, compared to 5 and 12%, respectively, in group A.

CONCLUSIONS

Nowadays, cadaveric liver donors are older, suffer more chronic diseases, die due to cerbrovascular diseases, remain longer in intensive care units and the livers are macroscopically worse compared to donors accepted 15 years ago.

Removing patients from the liver transplant wait list: A survey of US liver transplant programs

Guidelines are in place regarding who is a candidate for liver transplantation. Once a potential candidate is listed, there are no uniform guidelines indicating when he should be removed from the list because of a change in clinical status. A survey with 14 scenarios was sent to the medical and surgical directors of all liver transplant programs in the United States. In each scenario, clinical information was provided about a patient active on the transplant wait list. Data regarding a clinical change were provided, and responders were questioned whether they would remove the patient from the wait list. The scenarios were designed to address the issues of age, etiology of liver disease, renal dysfunction, respiratory failure, infection, failure to thrive, and social support. Two hundred four questionnaires were mailed with 47 responses (23%): 8 return to sender, 24 surgeons, and 15 hepatologists. All 11 United Network for Organ Sharing regions were represented. The responders were well distributed among university programs (n = 28), private practice programs (n = 10), and health maintenance organization programs (n = 1). Nine responses were from small-volume programs (< or =25 transplants), 12 were from medium-volume programs (26-50 transplants), and 18 were from large-volume programs (> or =51 transplants). There was wide variability between responders regarding which patients should be removed from the transplant wait list. Patient age and etiology of liver disease led to the greatest discordance among responders. In conclusion, there is a lack of agreement and standardization among US liver transplant programs regarding who should be removed from the wait list for a change in clinical status.

Current concepts in transplant surgery: liver transplantation today

INTRODUCTION

The discipline of liver transplantation (LTx) has been developed over the past decades, and LTx is now considered the gold standard for the treatment of patients with end-stage liver diseases and early liver tumors in cirrhotic livers. This procedure is now performed routinely in many transplant centers, and it has provided an enormous technical innovation to the field of hepatobiliary surgery. Allocation decision of liver organs is based on medical need and timing.

MATERIALS AND METHODS

The Mayo Model for End Stage Liver Disease based on patient-specific criteria was developed and applied to prioritize patients on the waiting list. From the donor aspects of LTx, sources of organ, excluding xenotransplantation, can be brain-dead donors, living donors, and non-heart-beating donors. Today, the majority of livers are procured from cadaveric donors. In addition to the conventional LTx, other types are living-donor LTx, reuse of grafts as domino transplantation, ex situ as well as in situ split LTx, and reduced-size LTx. The transplantation procedure consists of several steps including donor selection and management, liver procurement and preservation, back-table preparation, recipient operation with liver implantation, postoperative care, immunosuppression, and follow-up.

RESULTS

The postoperative complications are divided into surgical, non-surgical, and multifactorial complications. Surgical complications account about 34% of morbidities after LTx and are mainly categorized to vascular and biliary complications. The main medical ones are non-surgical bleeding and infections. The multifactorial complications include primary non- or poor function and small-for-size syndrome. The pretransplant outcome predictors of LTx can be divided into donor, recipient, operative, and postoperative factors.

CONCLUSION

LTx is now considered a safe and standardized procedure with a substantially improved graft and patient survival and acceptable morbidity rates. However, the new problems, including recurrence of hepatitis C or hepatocellular carcinoma, chronic biliary complications, opportunistic infections, and development of de-novo malignancies are the major problems affecting the long-term outcome of transplanted patients.

Predictors of outcomes after pediatric liver transplantation: an analysis of more than 800 cases performed at a single institution

BACKGROUND

Pediatric liver transplantation (PLTx) is the standard of care for treatment of liver failure in children. Unfortunately, there are few studies with substantial numbers of patients that identify outcomes predictors. The goal of this study was to determine factors that influence outcomes in a large, single-center cohort of PLTx.

STUDY DESIGN

This retrospective review between 1984 to 2006 included all recipients 18 years of age and younger undergoing PLTx. Multiorgan graft recipients were excluded (n = 48). Data sources included transplantation center database and hospital medical records. Outcomes measures were overall patient and graft survival. Demographic, laboratory, and perioperative variables were analyzed. Univariate and multivariate statistical analysis was undertaken using log-rank test and Cox's proportional hazards model. A p value < 0.05 was considered significant at the multivariate level.

RESULTS

Eight hundred fifty-two PLTx were performed in 657 children; 55% were girls, 45% were Hispanic, and median age was 29.5 months. Biliary atresia and acute liver failure were the most common causes of liver disease. Fifty-two percent were hospitalized before PLTx. Graft types were whole (75%) and segmental (25%). Indications for re-PLTx (n = 195) included graft nonfunction (22%), immunologic (34%), and vascular complications (35%). Overall 1-, 5-, and 10-year survival rates were 85%, 81%, and 78% (patient), and 78%, 72%, and 67% (graft). Independent significant predictors of worse patient survival were renal function, pretransplantation ventilator dependence, and causes of liver disease. Independent significant predictors of worse graft survival were renal function and warm ischemia time.

CONCLUSIONS

As one of the largest, single-center analyses of PLTx, this study enables accurate statistical analysis and demonstrates excellent longterm outcomes. Independent prognosticators of graft survival were renal function and warm ischemia time, and those for patient survival were renal function, mechanical ventilation, and causes of liver disease. These factors can aid in the medical decision making required for optimal use of scarce donor organs.

Expanding donor options: marginal, living, and split donors

One of the most important factors in the increasing number of liver transplantations performed in the United States is the growing acceptance of marginal grafts, which are defined as organs at increased risk for poor function or failure that may subject the recipient to greater risks of morbidity or mortality. Based on encouraging results, a growing number of liver transplantation centers are broadening their criteria for transplantation of marginal grafts. This article discusses the use of the extended criteria donor liver, split-liver, and living-donor liver transplantation.

Primary nonfunction (PNF) in the MELD Era: An SRTR database analysis

PNF following liver transplantation (LT) is an infrequent but life-threatening complication. Liver allocation under MELD is based upon recipient severity of illness, a known risk factor for the occurrence of PNF. The incidence of PNF since the application of MELD has not previously been reported. The SRTR database was studied since inception of MELD until September 2004 for all adult recipients of deceased donor LT. PNF was defined as graft loss or death within 14 days of LT secondary to PNF or without defined cause. A total of 10545 transplants met inclusion criteria and PNF occurred in 613 (5.81%) of recipients. Univariate analysis demonstrated donor age, serum creatinine >1.5 mg/mL, hypertension and CVA as risk factors for PNF. Recipient factors included life support, mechanical ventilation, use of inotropes, hemodialysis, initial status 1 and use of a shared transplant. In the multivariate model only donor age and recipient serum creatinine, bilirubin, on life support and status 1 at transplant were significant risk factors for PNF. In this analysis of PNF in the MELD era the incidence of PNF does not appear to have increased from prior reports. Risk factors for PNF are related to donor age and severity of recipient illness.

The economic impact of the utilization of liver allografts with high donor risk index

The disparity between the organ supply and the demand for liver transplantation (LT) has resulted in the growing utilization of 'marginal donor' organs. While economic outcomes for subsets of 'marginal' organs have been described for renal transplantation, similar analyses have not been performed for LT. Using UNOS data for 17 710 LTs performed between 2002 and 2005, we assessed the relationship between recipient model for end-stage liver disease (MELD) score, organ quality as defined by donor risk index (DRI, Feng et al. 2005) and hospital length of stay (LOS). Single-center cost-accounting data for 338 liver transplants were then analyzed with a multivariate linear regression model to determine the estimated cost associated with a day of LOS. Overall, 8.4% of donor organs were classified as high risk (DRI > 2-2.5) and 1.9% as very high risk (DRI > 2.5). In the lowest MELD group (0-10), the LOS difference between 'ideal' donors (DRI < 1.0) and very high risk (DRI > 2.5) was 10.6 days which was associated with an estimated incremental cost of $47 986. For patients with MELD >35, the average LOS increased from 23.2 to 41.8 days when very high DRI donors were used, resulting in an estimated increase in cost of nearly $84 000. We conclude that the use of marginal liver grafts results in increased hospital costs independent of recipient risk factors.

Combination of Extended Donor Criteria and Changes in the Model for End-Stage Liver Disease Score Predict Patient Survival and Primary Dysfunction in Liver Transplantation: A Retrospective Analysis

BACKGROUND

The purpose of this study was to analyze the impact of extended donor criteria (EDC) and of changes in the Model for End-Stage Liver Disease (MELD) score while waiting for liver-transplantation (Delta-MELD) on patient survival and initial graft function.

METHODS

We included 386 consecutive patients with end-stage liver disease who underwent orthotopic liver transplantation at the Medical University Vienna between 1997 and 2003. Primary outcome was patient survival and secondary outcome was initial graft function. EDC included: age >60 years, >4 days intensive medical care, cold ischemia time >10 hr, need for noradrenalin >0.2 microg/kg/min or doputamin >6 microg/kg/min, a donor peak serum sodium >155 mEq/L, a donor serum creatinine >1.2 mg/100 mL, and a body mass index >30.

RESULTS

Delta-MELD was significantly higher in the nonsurvivor population (P=0.01) and EDC showed a significant influence on initial graft function (P=0.01). Worsening in either Delta-MELD or the presence of at least two EDC was not associated with an increased risk of primary graft dysfunction and death. Worsening in Delta-MELD and the presence of at least two EDC was significantly associated with primary graft dysfunction (P=0.01) and death (P=0.008).

CONCLUSION

The combination of a liver recipient with worsening Delta-MELD and a potential donor with at least two EDC should be avoided.

Extended donor criteria have no negative impact on early outcome after liver transplantation: a single-center multivariate analysis

The organ shortage has driven many transplant centers to accept extended donor criteria and to modify graft allocation policies. This study was designed to analyze the impact of applying extended donor criteria (EDC) in orthotopic liver transplantation (OLT). Between December 2001 and December 2004, we performed 165 primary cadaveric whole OLTs. Up to three EDC, that is, ventilation >7 days; aminotransferases (ALT or AST) >3 x normal; bilirubin >3 mg/dL; anti-HBc or HBs Ag positivity; donor age >65 years; liver steatosis >40%; donor body mass index >30; cold ischemia time >14 hours; peak serum Na(+) >165 mmol/L; history of extrahepatic malignancy; or previous drug abuse were present in 55% of all grafts. Both univariate and multivariate analysis revealed that EDC status had no effect on graft or patient survival, the necessity for retransplantation, the length of intensive care/intermediate care unit stay, mechanical ventilation, complications, or posttransplant laboratory findings. Recipient age of >/=55 years was the only independent prognostic factor for survival, regardless of EDC. These findings suggested that the use of grafts from EDC donors are safe and expand the donor pool.

Temporal trends in early clinical outcomes and health care resource utilization for liver transplantation in the United States

INTRODUCTION

Procedures such as liver transplantation, which entail large costs while benefiting only a small percentage of the population, are being increasingly scrutinized by third-party payors. The purpose of our study was to conduct a longitudinal analysis of the early clinical outcomes and health care resource utilization for liver transplantation in the United States.

METHODS

The Nationwide Inpatient Sample database was used to conduct a longitudinal analysis of the clinical outcome and resource utilization data for liver transplantation procedures in adult recipients performed in the United States over three time periods (Period I: 1988-1993; Period II: 1994-1998: Period III: 1999-2003).

RESULTS

Compared to Period I, adult liver transplant recipients were more likely to be male, older, and non-White in Period III. Recipients were more likely to have at least one major comorbidity preoperatively than in Period I. The in-hospital mortality rate after liver transplantation decreased significantly from Period I to Period III, but the major intraoperative and postoperative complication rates increased over the same time period. Mean length of hospital stay decreased over the 15-year period, but the percentage of patients with a non-routine discharge status increased.

CONCLUSION

Our findings indicate that the rate of postoperative complications and non-routine discharges after liver transplantation is increasing. However, these negative changes in the cost-outcomes relationship for liver transplantation are balanced by improving postoperative survival rates and reductions in the length of hospital stay.

Ischemia-Reperfusion Injury is More Severe in Older Versus Young Rat Livers

BACKGROUND

Hepatic warm ischemia during surgery remains a significant problem, particularly in organs with possible baseline dysfunction. The objective of this study was to investigate whether age influences the degree of warm ischemia-reperfusion injury in rat livers.

MATERIALS AND METHODS

The left and median lobes of young (3 months) and adult (9 months) male rats were exposed to 75 min of ischemia followed by reperfusion. Each age group was divided into two sub-groups. One sub-group was observed for 8 h, whereas the other was allowed to survive. Animals in the 8-h groups (young and adult) were sacrificed, and blood and tissue were taken to determine liver enzymes, neutrophil accumulation, and blood metabolic profiles and to examine the histology.

RESULTS

Hepatocellular injury was significantly greater in adult rats after 8 h of reperfusion, as determined by hepatic enzyme levels and histology. Liver enzyme levels were massively elevated in adult rats and were significantly higher compared with those of young rats. The degree of necrosis and neutrophil accumulation was significantly higher in adult rats. After 8 h of reperfusion, the metabolic profiling of the blood revealed elevated levels of creatine, creatinine, allantoin, and amino acids (tyrosine, methionine) in the adult rats. At 24 h of reperfusion, all adult rats died, in contrast to young rats, which all survived.

CONCLUSIONS

Aging in rats is associated with greater hepatocellular injury and poor survival rate after 75 min of warm hepatic ischemia.

Continued influence of preoperative renal function on outcome of orthotopic liver transplant (OLTX) in the US: where will MELD lead us?

Renal function is a component of the Model for End Stage Liver Disease (MELD), We queried the 1999-2004 OPTN/UNOS database to determine whether preoperative renal function remained an important determinant of survival in primary deceased donor liver transplant alone patients (DDLTA) or primary combined kidney liver transplant patients (KLTX). We examined preoperative creatinine, renal replacement therapy (RRT), incidence of KLTX, and patient survival in the 34 months before and after introduction of MELD and performed a multivariate Cox regression analysis of time to death. Preoperative renal function is an independent predictor of survival in DDLTA but not in KLTX. When compared to DDLTA with a preoperative serum creatinine of 0-0.99 mg/dL, patients with serum creatinine from 1-1.99 mg/dL, >2.0 mg/dL, those requiring RRT, and those receiving KLTX had a relative risk of death following transplant of 1.11, 1.58, 1.77, and 1.44 respectively. KLTX requiring RRT had better survival than DDLTA requiring RRT. Since introduction of MELD, KLTX, preoperative creatinine, and number of patients requiring preoperative RRT have increased. Despite this, patient survival following orthotopic liver transplant (OLTX) in the 34 months after introduction of MELD is not different than prior to introduction of MELD.

Impact of recipient MELD score on resource utilization

The model for end stage liver disease (MELD) system prioritizes deceased donor organs to the sickest patients who historically require higher healthcare expenditures. Limited information exists regarding the association of recipient MELD score with resource use. Adult recipients of a primary liver allograft (n = 222) performed at a single center in the first 27 months of the MELD system were analyzed. Costs were obtained for each recipient for the 12 defined categories of resource utilization from the time of transplant until discharge. True (calculated) MELD scores were used. Inpatient transplant costs were significantly associated with recipient MELD score (r = 0.20; p = 0.002). Overall 1-year patient survival was 85.0% and was not associated with MELD score (p = 0.57, log rank test). Recipient MELD score was significantly associated with costs for pharmacy, laboratories, radiology, dialysis and physical therapy. Multivariate linear regression revealed that MELD score was most strongly associated with cost compared to other demographic and clinical factors. Recipient MELD score is correlated with transplant costs without significantly impacting survival.

Differentially expressed genes in postperfusion biopsies predict early graft dysfunction after liver transplantation

BACKGROUND

Preservation induced injury is a major contributing factor to early graft dysfunction in liver allograft recipients. We hypothesized that changes in gene expression represent the earliest indicator of ischemia/reperfusion-related injuries measurable in the graft and could be used as prognostic marker for the occurrence of graft-related complications.

METHODS

We studied the expression of 67 genes, known to play a role in acute inflammatory processes by real-time polymerase chain reaction in 59 postperfusion biopsies. The level of expression was correlated with the occurrence of graft-related complications.

RESULTS

We identified six genes that were significantly correlated with the occurrence of early graft dysfunction (Spearman test, two-tailed; P<0.05). High C-reactive protein (CRP) gene expression levels correlated significantly with the need of therapeutic interventions due to graft-related complications (P=0,011). Furthermore, five genes related to vascular endothelial cell physiology (CTGF, WWP2, CD274, VEGF. and its receptor FLT1) showed significantly reduced expression in the postperfusion biopsies of patients with need of therapeutic interventions due to graft-related complications in the first month (P<0.05). Using a risk score based on the expression of these five genes, complications could be predicted with 96% sensitivity (ROC analysis, specificity: 74%, positive predictive value: 72%, negative predictive value: 96%).

CONCLUSION

Quantitative gene expression analysis in postperfusion biopsies may be a valuable tool to prospectively identify patients at risk for early clinical allograft dysfunction after liver transplantation.