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Liver transplantation in patients with alcohol-related liver disease: current status and future directions. Lancet Gastroenterol Hepatol 2020; 5:507-514. [DOI: 10.1016/s2468-1253(19)30451-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/15/2019] [Accepted: 12/19/2019] [Indexed: 12/19/2022]
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Memeo R, de'Angelis N, Salloum C, Compagnon P, Laurent A, Feray C, Duvoux C, Azoulay D. Clinical outcomes of right-lobe split-liver versus orthotopic liver transplants from donors more than 70 years old. Prog Transplant 2018; 25:243-50. [PMID: 26308784 DOI: 10.7182/pit2015303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Context-The imbalance between the organ supply and the number of potential transplant recipients led to consideration of expanded-criteria liver donors. Objective-To compare right-lobe split-liver transplants (RL-SLTs) with orthotopic liver transplants (OLTs) from donors more than 70 years old (OLT-O) and OLTs from donors less than 55 years old (OLT-Y). Methods-Seventy-one patients who received an RL-SLT were matched for age, sex, and Model for End-stage Liver Disease score with 71 patients who underwent OLT-O and 142 patients who underwent OLT-Y. Clinical outcomes were compared between groups. Results-Longer operation time was associated with RL-SLT (P< .001) as well as more blood loss (P= .03) and transfusions (P= .05). Postoperative morbidity was less in the OLT-Y group, with a lower rate of grades III to IV Clavien-Dindo complication (30%), compared with values in OLT-O (52%) and RL-SLT (38%). Kaplan-Meier analysis demonstrated better 1-year and 3-year survival rates in the OLT-Y group (97% and 92%, respectively), compared with 92% and 86.3%, respectively, in the RL-SLT group; and 84.5% and 73%, respectively, in the OLT-O group (P = .03). Kaplan-Meier analysis also demonstrated differences between the groups in terms of 1-year and 3-year graft survival rates, which were 92% and 86%, respectively, in OLT-Y; 77% and 66%, respectively, in the OLT-O, and 84.2% and 76.6%, respectively, in the RL-SLT group (P= .01). Conclusion-Even if OLT-Y guarantees better patient and graft survival, both RL-SLT and OLT-O can be used safely to expand the pool of liver donors, showing acceptable clinical results and complications rates.
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Affiliation(s)
- Riccardo Memeo
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Nicola de'Angelis
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Chady Salloum
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Philipe Compagnon
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Alexis Laurent
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Cyrille Feray
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Cristoph Duvoux
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Daniel Azoulay
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
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Burra P, Zanetto A, Germani G. Liver Transplantation for Alcoholic Liver Disease and Hepatocellular Carcinoma. Cancers (Basel) 2018; 10:E46. [PMID: 29425151 PMCID: PMC5836078 DOI: 10.3390/cancers10020046] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 12/11/2022] Open
Abstract
Hepatocellular carcinoma is one of the main important causes of cancer-related death and its mortality is increasingly worldwide. In Europe, alcohol abuse accounts for approximately half of all liver cancer cases and it will become the leading cause of hepatocellular carcinoma in the next future with the sharp decline of chronic viral hepatitis. The pathophysiology of alcohol-induced carcinogenesis involves acetaldehyde catabolism, oxidative stress and chronic liver inflammation. Genetic background plays also a significant role and specific patterns of gene mutations in alcohol-related hepatocellular carcinoma have been characterized. Survival is higher in patients who undergo specific surveillance programmes than in patients who do not. However, patients with alcohol cirrhosis present a significantly greater risk of liver decompensation than those with cirrhosis due to other aetiologies. Furthermore, the adherence to screening program can be suboptimal. Liver transplant for patients with Milan-in hepatocellular carcinoma represents the best possible treatment in case of tumour recurrence/progression despite loco-regional or surgical treatments. Long-term result after liver transplantation for alcohol related liver disease is good. However, cardiovascular disease and de novo malignancies can significantly hamper patients' survival and should be carefully considered by transplant team. In this review, we have focused on the evolution of alcohol-related hepatocellular carcinoma epidemiology and risk factors as well as on liver transplantation in alcoholic patients with and without hepatocellular carcinoma.
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Affiliation(s)
- Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128 Padua, Italy.
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128 Padua, Italy.
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Via Giustiniani 2, 35128 Padua, Italy.
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Mathurin P, Bataller R. Trends in the management and burden of alcoholic liver disease. J Hepatol 2015; 62:S38-46. [PMID: 25920088 PMCID: PMC5013530 DOI: 10.1016/j.jhep.2015.03.006] [Citation(s) in RCA: 213] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 03/05/2015] [Accepted: 03/05/2015] [Indexed: 12/16/2022]
Abstract
Alcoholic liver disease (ALD) is the most prevalent cause of advanced liver disease in Europe and is the leading cause of death among adults with excessive alcohol consumption. There is a dose-response relationship between the amount of alcohol consumed and the risk of ALD. The relative risk of cirrhosis increases in subjects who consume more than 25 g/day. The burden of alcohol-attributable liver cirrhosis and liver cancer is high and is entirely preventable. Health agencies should develop population-based policies to reduce the prevalence of harmful and/or hazardous alcohol consumption and foster research in this field to provide new diagnostic and therapeutic tools. Disease progression of patients with ALD is heavily influenced by both genetic and environmental factors. Non-invasive methods for the diagnosis of fibrosis have opened new perspectives in the early detection of advanced ALD in asymptomatic patients. Alcoholic hepatitis, the most severe form of ALD, carries a high short-term mortality (around 30-50% at 3 months). Corticosteroids improve short-term survival in patients with severe alcoholic hepatitis but duration of therapy should be adapted to early response. Liver transplantation is the best option for patients with severe liver dysfunction. However, alcohol relapse after transplantation remains a critical issue and drinking habits of transplanted patients need to be routinely screened.
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Affiliation(s)
- Philippe Mathurin
- Service Maladie de l'Appareil Digestif and INSERM U995, Univ Lille 2, CHRU Lille, France.
| | - Ramon Bataller
- Departments of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Abstract
There are three possible policies for prioritization for liver transplantation: medical urgency, utility and transplant benefit. The first is based on the severity of cirrhosis, using Child-Turcotte-Pugh score and, more recently, the Model for End-stage Liver Disease (MELD) score, or variants of MELD, for allocation. Although prospectively developed and validated, the MELD score has several limitations, including interlaboratory variations for measurement of serum creatinine and international normalized ratio of prothrombin time, and a systematic adverse female gender bias. Adjustments to the original MELD equation and new scoring systems have been proposed to overcome these limitations; incorporation of serum sodium improves its predictive accuracy. The MELD score poorly predicts outcomes after liver transplantation due to the absence of donor factors incorporated into the scoring system. Several utility models are based on donor and recipient characteristics. Combined poor recipient and donor characteristics lead to very poor outcomes, which in a utility system would be considered unacceptable. Finally, transplant benefit models rank patients according to the net survival benefit that they would derive from transplantation. However, complex statistical models are required, and unmeasured characteristics may unduly affect the models. Well-designed prospective studies and simulation models are necessary to establish the optimal allocation system in liver transplantation.
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Affiliation(s)
- Evangelos Cholongitas
- 4th Department of Internal Medicine, Medical School of Aristotle University, Hippocration General Hospital of Thessaloniki, 54642 Thessaloniki, Greece
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Gallegos-Orozco JF, Yosephy A, Noble B, Aqel BA, Byrne TJ, Carey EJ, Douglas DD, Mulligan D, Moss A, de Petris G, Williams JW, Rakela J, Vargas HE. Natural history of post-liver transplantation hepatitis C: A review of factors that may influence its course. Liver Transpl 2009; 15:1872-81. [PMID: 19938138 DOI: 10.1002/lt.21954] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Our aim was to assess long-term survival in patients transplanted for HCV-related end-stage liver disease (ESLD) and evaluate potentially modifiable predictors of survival. We performed a retrospective analysis of adult liver transplants (LT) at our institution for HCV-related ESLD since the program's inception. Pertinent demographic, clinical, and biochemical information was retrieved from electronic medical records and histological data from 990 per-protocol liver biopsies were collected. Three hundred eighty LT were performed at our institution during the study period, 206 patients were transplanted for HCV-related ESLD; 6 died within 30 days of transplantation and were not included. The remaining 200 recipients (DDLT 168 LDLT 32) constituted the evaluable population. The demographics were as follows: 150 males, median age 53 years; median donor age 39 years; hepatocellular carcinoma (HCC) in 26%. Overall 1-, 5-, and 7-year survival: 95%, 81%, and 79%; median survival 43 months, mortality 15%. Significant HCV recurrence (HAI >or=6 and/or fibrosis >or=2) was present in 49%, "early recurrence" (within 1 year of LT) in 30.5% and biopsy-proven acute rejection was present in 27%. Factors with a significant negative impact on patient survival included: fibrosis stage >or=2 at 12-month biopsy, advanced donor age, history of HCC and early acute rejection. Survival was similar regardless of the donor type (DDLT vs. LDLT). Early and aggressive HCV recurrence has a very heavy toll on patient survival. Prompt recognition and treatment of "rapid fibrosers" may impart benefit. As has been described before, avoidance of rejection and selection of young donors for HCV-positive recipients will also improve survival in this population. On the basis of our findings, LDLT is a good option for HCV-positive recipients.
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Abstract
The widespread availability of transplantation in most major medical centers in the United States, together with a growing number of transplant candidates, has made it necessary for primary care providers, especially internal medicine and family practice physicians to be active in the clinical care of these patients before and after transplantation. This review provides an overview of the liver transplantation process, including indications, contraindications, time of referral to a transplant center, the current organ allocation system, and briefly touches on the expanding field of living donor liver transplantation.
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Affiliation(s)
- Juan F Gallegos-Orozco
- Division of Gastroenterology, Department of Medicine, Mayo Clinic Arizona, 13400 E. Shea Boulevard, Scottsdale, AZ 85259, USA
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Overview of the MELD score and the UNOS adult liver allocation system. Transplant Proc 2008; 39:3169-74. [PMID: 18089345 DOI: 10.1016/j.transproceed.2007.04.025] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Accepted: 04/18/2007] [Indexed: 12/15/2022]
Abstract
On February 27, 2002, the United Network for Organ Sharing (UNOS) introduced a new allocation policy for cadaveric liver transplants, based on the Model for End-Stage Liver Disease (MELD) score. This new policy stratifies the patients based on their risk of death while on the waiting list. We analyzed the background and main features of this new allocation policy to evaluate the effects on waiting list dynamics as well as the accuracy of MELD as a predictor of pretransplantation mortality and posttransplantation outcome. MELD has proved to be accurate as a predictor of waiting list mortality, but seems to be less accurate to predict posttransplantation outcome. Immediate effects of the new policy were a reduction in the waiting list, while organs were primarily directed to sicker patients with reduced waiting times. There was a statistically but not significantly reduced number of patients removed from the list due to death or severity of sickness. The balance between medical urgency and transplant benefit is still to be defined as is the relationship between pretransplantation criteria and posttransplantation outcomes, and the way this relationship should be included in the allocation policy.
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Mathurin P, Lucey MR. A patient with alcoholic liver failure referred for liver transplantation. Liver Transpl 2007; 13:S83-6. [PMID: 17969071 DOI: 10.1002/lt.21338] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Philippe Mathurin
- Service d'Hépato-Gastroentérologie, Höpital Claude Huriez, Lille, France.
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Ravaioli M, Grazi GL, Ercolani G, Cescon M, Pinna AD, Ballardini G. The Future Challenge in the MELD Era: How to Match Extended-Use Donors and Sick Recipients. Transplantation 2006; 82:987-8. [PMID: 17038919 DOI: 10.1097/01.tp.0000238705.29588.fc] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ravaioli M, Grazi GL, Ercolani G, Cescon M, Del Gaudio M, Zanello M, Ballardini G, Varotti G, Vetrone G, Tuci F, Lauro A, Ramacciato G, Pinna AD. Liver allocation for hepatocellular carcinoma: a European Center policy in the pre-MELD era. Transplantation 2006; 81:525-30. [PMID: 16495798 DOI: 10.1097/01.tp.0000198741.39637.44] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Policies to decrease dropout during waiting time for liver transplantation (LT) are under debate. METHODS We evaluated the allocation system from 1996 to 2003, when recipients had priority related to Child-Pugh score and donors >60 years were mainly offered to recipients with hepatocellular carcinoma (HCC). The outcomes of 656 patients with chronic liver disease (142 HCC and 514 non-HCC) listed for LT were prospectively evaluated, considering recipient and donor features. RESULTS Transplantation and dropout rates were similar between HCC and non-HCC patients: 64.1% vs. 70.6% and 26% vs. 22.6%. Multivariate analysis showed the probability of being transplanted within 3 months was related to Child-Pugh score >10 and to HCC, whereas the probability of being removed from the list within 3 months was only related to Child-Pugh score >10. HCC patients had a lower median waiting time (97 vs. 197 days, P<0.001), a higher rate of donors > 60 years (50.5% vs. 33.5%, P<0.005) and with steatosis (31.6% vs. 14.3%, P<0.01), but a lower Child-Pugh score (9.1+/-2.1 vs. 9.6+/-1.7, P<0.05) than non-HCC patients. The 5-year patient survival was comparable since registration on the list and since LT: 56.9% and 77% in the HCC group vs. 61.4% and 79% in the non-HCC patients. Donors > 60 years affected outcome after LT in the non-HCC group, but not in the HCC patients. CONCLUSION By allocating donors >60 years mainly to HCC patients, we controlled dropout without affecting their survival and the outcome of non-HCC patients.
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Affiliation(s)
- Matteo Ravaioli
- Department of Liver and Multiorgan Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy
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Buenadicha AL, Martín LG, Martín EE, Pajares ADP, Pérez AM, Seral CC, Marugán RB. Assessment of short-term survival after liver transplant by the Model for End-Stage Liver Disease. Transplant Proc 2006; 37:3881-3. [PMID: 16386571 DOI: 10.1016/j.transproceed.2005.09.165] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
UNLABELLED The Model for End-Stage Liver Disease (MELD) score has demonstrated the ability to predict mortality among patients with chronic liver disease on the liver waiting list. The aim of this study was to assess the capability of the MELD score to correctly predict posttransplantation survival in Spain and to determine specific thresholds of MELD above which liver transplantation should be discouraged and the patient removed from the waiting list. METHODS In this study, we retrospectively applied the MELD score to 168 patients at time of transplantation to estimate 1-month and 3-month posttransplant survivals by stratifying them into four groups: group A, MELD score < 10; group B, MELD score 10-18; group C, MELD score 19-24; group D, MELD score > 24. RESULTS One-, 2-, and 3-month survivals were 84.3%, 80% and 79.5%, respectively. One-, 2-, and 3-month survivals in group A (18 patients) were identical (77.8%). In group B (80 patients), 1-month survival was 84.8%, and 2- and 3-month survivals were 78.4%. In group C (42 patients) 1-month survival was 90.5% and 2- and 3-month survivals were 88%. One-, 2-, and 3-month survivals in group D (28 patients) were 77.9%, 74%, and 70%, respectively. We defined a new group (group E) formed by patients with MELD score < or =24. When we compared 1-, 2-, and 3-month survival rates in group E (85.6%, 81.25%, and 81.25%, respectively) with survival rates in group D, the difference was not significant (P > .05). CONCLUSIONS Although overall outcomes of patients whose MELD scores were high at the time of liver transplantation were inferior to those of patients whose MELD scores were lower, there was no significant difference for specific thresholds of MELD above which liver transplantation should be discouraged and the patient removed from the waiting list.
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Affiliation(s)
- A L Buenadicha
- Department of Digestive Surgery, Transplant Unit, Hospital Ramón y Cajal, Universidad de Alcalá, Madrid, Spain.
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Affiliation(s)
- Michael R Lucey
- Section of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA.
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