Utilization of extended donor criteria liver allograft: Is the elevated risk of failure independent of the model for end-stage liver disease score of the recipient?

Liver transplantation using donation after cardiac death donors: long-term follow-up from a single center

There is a lack of universally accepted clinical parameters to guide the utilization of donation after cardiac death (DCD) donor livers and it is unclear as to which patients would benefit most from these organs. We reviewed our experience in 141 patients who underwent liver transplantation using DCD allografts from 1993 to 2007. Patient outcomes were analyzed in comparison to a matched cohort of 282 patients who received livers from donation after brain death (DBD) donors. Patient survival was similar, but 1-, 5- and 10-year graft survival was significantly lower in DCD (69%, 56%, 44%) versus DBD (82%, 73%, 63%) subjects (p < 0.0001). Primary nonfunction and biliary complications were more common in DCD patients, accounting for 67% of early graft failures. A donor warm ischemia time >20 min, cold ischemia time >8 h and donor age >60 were associated with poorer DCD outcomes. There was a lack of survival benefit in DCD livers utilized in patients with model for end-stage liver disease (MELD) < or =30 or those not on organ-perfusion support, as graft survival was significantly lower compared to DBD patients. However, DCD and DBD subjects transplanted with MELD >30 or on organ-perfusion support had similar graft survival, suggesting a potentially greater benefit of DCD livers in critically ill patients.

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.

Preoperative assessment of the risk factors that help to predict the prognosis after living donor liver transplantation

BACKGROUND

The purpose of this study was to analyze various risk factors and to assess the preoperative risk score, which can predict the prognosis after living donor liver transplantation (LDLT).

METHODS

From February 2002 to August 2007, 84 adult to adult living donor liver transplantation donors and recipients were analyzed. First, the donor, recipient, and intraoperative factors were examined by univariate and multivariate analyses. We then gave a score of one point for each significant marginal factor (total point scores were called "risk score") and each risk score was examined by univariate analyses.

RESULTS

Recipients with the donor age 50 years or older, Model for End-Stage Liver Disease (MELD) score (> or =21), and hepatitis C virus-positive status had a significantly poor survival. Recipients between the risk score of 0 vs. scores of 2 + 3 (p < 0.001, log-rank) and risk score of 1 vs. scores of 2 + 3 (p = 0.003, log-rank) had significantly different survival.

CONCLUSIONS

Preoperative assessment of the risk score might help to predict recipient outcomes after living donor liver transplantation.

Report of the Paris consensus meeting on expanded criteria donors in liver transplantation

Because of organ shortage and a constant imbalance between available organs and candidates for liver transplantation, expanded criteria donors are needed. Experience shows that there are wide variations in the definitions, selection criteria, and use of expanded criteria donors according to different geographic areas and different centers. Overall, selection criteria for donors have tended to be relaxed in recent years. Consensus recommendations are needed. This article reports the conclusions of a consensus meeting held in Paris in March 2007 with the contribution of experts from Europe, the United States, and Asia. Definitions of expanded criteria donors with respect to donor variables (including age, liver function tests, steatosis, infections, malignancies, and heart-beating versus non-heart-beating, among others) are proposed. It is emphasized that donor quality represents a continuum of risk rather than "good or bad." A distinction is made between donor factors that generate increased risk of graft failure and factors independent of graft function, such as transmissible infectious disease or donor-derived malignancy, that may preclude a good outcome. Updated data concerning the risks associated with different donor variables in different recipient populations are given. Recommendations on how to safely expand donor selection criteria are proposed.

Impact of the model for end-stage liver disease allocation policy on the use of high-risk organs for liver transplantation

BACKGROUND & AIMS

Although priority for liver transplantation is determined by the model for end-stage liver disease (MELD) score, the quality of organs used is subject to physician discretion. We aimed to determine whether implementation of MELD affected the quality of organs transplanted, the type of patients who receive the higher-risk organs, and the impact of these changes on their posttransplant survival.

METHODS

Data were analyzed from the United Network for Organ Sharing of adults who underwent deceased-donor liver transplantation between January 1, 2007, and August 1, 2007 (n = 47,985). Dependent variables included the donor risk index (a continuous variable that measures the risk of graft failure associated with a particular organ) and patient survival after transplantation.

RESULTS

The overall organ quality of transplanted livers has worsened since MELD implementation, with an increase in the donor risk index equivalent to a 4% increased risk of graft failure after adjusting for temporal trends (P < .001). This was accompanied by a shift from using the higher-risk organs in the more urgent patients (in the pre-MELD era) to using the higher-risk organs in the less urgent patients (in the post-MELD era). Posttransplant survival has worsened over time (hazard ratio, 1.017/y; P = .005) among the less urgent patients (MELD scores, <20); mediation analysis suggests this change in survival was caused primarily by changes in organ quality.

CONCLUSIONS

As an unintended consequence of the MELD allocation policy, patients that are least in need of a liver transplant now receive the highest-risk organs. This has reduced posttransplant survival in recent years among patients with low MELD scores.

Elderly donors for HCV(+) versus non-HCV recipients: patient survival following liver transplantation

INTRODUCTION

Chronic liver failure due to hepatitis C virus (HCV)-related cirrhosis is the leading indication for liver transplantation. Inferior long-term results have been reported for liver transplantation in HCV(+) patients, especially when marginal donor livers are utilized.

AIM

The aim of this study was to analyze retrospectively the outcome of liver transplantation patients from elderly donors in the case of HCV(+) versus non-HCV recipients.

METHODS

Among 330 liver transplantations performed from January 1994 to December 2006, we selected 244 excluding acute hepatic failure, children, and retransplants. Among these patients we analyzed 232 subjects who underwent the piggyback technique. Donor risk index (DRI) as described by Feng et al was applied using 1.7 as a cutoff value. We used Kaplan-Meier survival and Cox hazard regression analyses. We studied 14 donor variables using descriptive statistical tests.

RESULTS

There were 148 (63.8%) HCV(+) recipients and 84 (36.2%) non-HCV liver transplant recipients. Among HCV(+) recipients, 130/148 (87.8%) patients received livers, from donors less than 50 years old, and 18/148 (12.2%), over 50 years. The descriptive statistics of patient categorical variables are shown in Table 1, and continuous variables in Table 2. The cumulative proportional survival curves are shown in Figs 1 and 2. Mortality predictive factors in HCV(+) liver transplant recipients with donor age > 50 years old as determined by Cox hazard regression showed that death risk was increased with hazard ratios for warm ischemia = 1.01 (P = .001); for red blood cell intraoperative requirements = 2.63 (P = .003); for Child-Turcotte-Pugh classification points = 2.25 (P = .04), and for DRI > 1.7 = 2.19 (P = .03). In conclusion, advancing donor age, as well as the use of nonideal donors, intraoperative bleeding, and prolonged warm ischemia, had an adverse influence on patient survival for HCV(+) recipients.

Liver transplantation: an update 2008

PURPOSE OF REVIEW

Expansion of the donor pool for liver transplantation is a priority. Management of hepatitis C and hepatocellular carcinoma has focused on decreasing recurrence rates after transplantation.

RECENT FINDINGS

Expansion of the pool of donors has focused on live donor liver transplantation and extended criteria donor grafts. The results of live donor liver transplantation are equivalent to those of deceased donor liver transplantation. The use of extended criteria donor grafts has increased significantly. The results are associated with decreased graft survival with the use of grafts that have multiple factors considered as extended criteria for transplantation, particularly in high-risk individuals such as critically ill recipients. Judicious matching of extended criteria donors with recipients is essential to reduce waiting list mortality without reducing posttransplantation survival. The role of pretransplant ablation therapy for hepatocellular carcinoma is evolving to reduce tumor progression and dropout on the list as well as to influence posttransplant recurrence rates. Antiviral and immunosuppressive strategies in reducing the severity of hepatitis C virus recurrence are discussed as is retransplantation for the disease.

SUMMARY

Expansion of the donor pool with the use of extended criteria donors and live donor liver transplantation is a major challenge. Transplantation for hepatocellular carcinoma and hepatitis C virus relapse are major areas of research.

Critical use of extended criteria donor liver grafts in adult-to-adult whole liver transplantation: a single-center experience

This study presents our experience with the use of extended criteria donor (ECD) liver grafts. One hundred fifteen liver transplants were divided into 2 groups: standard (S) and nonstandard (NS). Fifty-eight patients in group S received a liver procured from an ideal donor, whereas 57 patients in group NS received an organ from an ECD. On the basis of the number of risk factors, patients were divided into 3 subgroups: the S group with 58 receiving a standard graft, the NS1 group with 44 receiving a graft with 1 or 2 risk factors, and the NS2 group with 13 receiving a graft with 3 to 4 risk factors. Patient survival was not different at 6, 12, and 24 months (P > 0.05), whereas graft survival was different (P = 0.0079). Both patient survival and graft survival were influenced by the cumulative number of risk factors. The univariate analysis of the donor risk factors detected hemodynamic factors as predictive of graft failure (P = 0.024) and death (P = 0.018). In the multivariate analysis, which was adjusted for recipient age and donor and recipient gender, hemodynamic risk factors and Model for End-Stage Liver. Disease score in the recipient were the only variables independently associated with graft failure (P = 0.006, P = 0.012, negatively). Finally, we observed a reduction of dropout from the list to 9% from 14.1% (P = 0.04) and of mortality on the list to 32.55% from 41.01% (P = 0.11). Critical use of ECD liver grafts allowed recipients in the waiting list to have a greater chance of being transplanted.