1
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Bajwa R, Singh L, Molina Garcia S, Imperio-Lagabon K, Sims OT, Modaresi Esfeh J. Post liver transplant short term and survival outcomes in patients living with obesity. Dig Liver Dis 2024:S1590-8658(24)00720-5. [PMID: 38729903 DOI: 10.1016/j.dld.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 05/12/2024]
Abstract
The objectives of our study were to examine and compare patient and graft survival over a 5-year period across BMI groups, and examine immediate and short-term complications post-LT. This was a retrospective study that examined all liver transplants that occurred at our institution between January 2015-October 2022. Patients were divided into 4 BMI groups (n = 888): normal-overweight (BMI 18.5- 29.9 kg/m2), class I obesity (BMI 30-34.9 kg/m2), class II obesity (BMI 35-39.9 kg/m2), and class III obesity (BMI ≥40 kg/m2) patients. Kaplan Meier curves with the log rank test were created to assess survival outcomes and multivariate Cox regression analysis was performed. Patient and graft survival did not differ statistically between each BMI group. However, patient survival was significantly lower in patients with BMI ≥40 compared to patients with BMI <40. In multivariate analysis, BMI ≥40, admission to the ICU, and age were independent predictors of increased risk of mortality. Infection, arrhythmia, cardiac arrest, and myocardial infarction were more frequent immediate complications in the class III obesity group. Efforts to closely monitor patients with BMI ≥40 post LT to maximize survival are needed. Further studies are needed to improve post LT survival among patients with BMI ≥40.
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Affiliation(s)
- Ramanpreet Bajwa
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
| | - Lovepreet Singh
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Sofia Molina Garcia
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | | | - Omar T Sims
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Jamak Modaresi Esfeh
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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2
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Artzner T, Legeai C, Antoine C, Jasseron C, Michard B, Faitot F, Schneider F, Bachellier P. Liver transplantation for critically ill cirrhotic patients: Results from the French transplant registry. Clin Res Hepatol Gastroenterol 2022; 46:101817. [PMID: 34607069 DOI: 10.1016/j.clinre.2021.101817] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 02/04/2023]
Abstract
This study describes the population of cirrhotic patients who were transplanted from the ICU in France, identifying pre-transplant risk factors of post-transplant mortality and describing geographic variations in ICU transplant activity. Cirrhotic patients transplanted between 2008 and 2018 were included through the national transplant registry. The demographic, clinical and biological characteristics of the patients transplanted from the ICU were compared to cirrhotic patients who were transplanted from home or from the hospital. Risk factors of post-transplant one-year mortality were identified in uni- and multivariable analysis within the population transplanted from the ICU. Funnel plots were used to illustrate center-specific differences in ICU transplant activity. 1,047 cirrhotic patients were transplanted from the ICU during the study period. While the national rate of transplants performed from the ICU was 14.3% the absolute number and the rate of cirrhotic patients transplanted from the ICU varied significantly from one center to another, ranging from 6.6% to 22.8% (p < 0.05). Three recipient-associated independent risk factors one-year post-LT mortality were identified in the population transplanted from the ICU: age > 50 years (HR 1.65, 95%CI 1.16-2.36), p = 0.005), diabetes (HR 1.46, 95%CI 1.07-1.98, p = 0.02) and intubation (HR2.12, 95%CI 1.62-2.78), p < 0.001). Donor age was also independently associated with mortality (HR 1.01, 95%CI 1.01-1.02, p < 0.001). Funnel plots showed significant differences in the proportion of patients transplanted from the ICU and the distribution of risk factors across French transplant centers, especially the inclination to transplant intubated patients. This study underlines the increased post-transplant mortality among cirrhotic patients transplanted from the ICU. It identifies four clinically pertinent independent risk factors associated with post-transplant mortality in this specific sub-group of transplant candidates. Finally, it illustrates how diverse the landscape of liver transplantation for critically ill cirrhotic patients is across a single country, despite a unified allocation algorithm.
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3
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Bezinover D, Geyer NR, Dahmus J, Chinchilli VM, Stine JG. A decline in functional status while awaiting liver transplantation is predictive of increased post-transplantation mortality. HPB (Oxford) 2022; 24:825-832. [PMID: 34772623 PMCID: PMC10691403 DOI: 10.1016/j.hpb.2021.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 08/27/2021] [Accepted: 10/19/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Functional status (FS) is dynamic and changes over time. We examined how changes in FS while awaiting liver transplantation influence post-transplant outcomes. METHODS Data on adult liver transplants performed in the United States during the MELD era were obtained through September 2020. Patient and graft survival were compared between groups with no change or improved FS, and those with worsening FS. RESULTS Of the 90,210 transplant recipients included in the analysis, 39,193 (43%) had worsening FS, which was associated with longer waiting-list time (187 vs. 329 days, p < 0.001) and worse patient survival after liver transplant (1858 vs. 1727 days, p < 0.001). A consistent and dose-dependent relationship was observed for each 10-point decrease in Karnofsky Performance Score and post-transplant survival. Multivariable regression analysis confirmed that a decline in FS was associated with worse patient survival (HR 1.15, p < 0.001). Similar findings were observed for graft survival. CONCLUSION A decline in FS on the waiting-list is associated with significantly greater post-liver transplant mortality in recipients. These results should be taken into consideration when allocating organs and determining transplant candidacy. Strategies to optimize FS prior to transplantation should be prioritized as even subtle decreases in FS are associated with inferior post-transplantation outcomes.
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Affiliation(s)
- Dmitri Bezinover
- Division of Transplant Anesthesia, Department of Anesthesia and Perioperative Medicine, 500 University Drive, Hershey, PA, 17033, USA; Liver Center, The Pennsylvania State University, Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Nathaniel R Geyer
- Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, PA, 17033, USA
| | - Jessica Dahmus
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University, Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Vernon M Chinchilli
- Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, PA, 17033, USA
| | - Jonathan G Stine
- Liver Center, The Pennsylvania State University, Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA; Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, PA, 17033, USA; Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University, Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA; Cancer Institute, The Pennsylvania State University, Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
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4
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Mahmud N, Reddy KR. Con: Patients With Acute-on-Chronic Liver Failure Should Not Receive Priority on the Waiting List. Clin Liver Dis (Hoboken) 2022; 19:207-212. [PMID: 35662865 PMCID: PMC9135147 DOI: 10.1002/cld.1193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/22/2021] [Accepted: 11/28/2021] [Indexed: 02/04/2023] Open
Abstract
Content available: Audio Recording.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and HepatologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - K. Rajender Reddy
- Division of Gastroenterology and HepatologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
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5
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Textbook Outcome as a Quality Metric in Liver Transplantation. Transplant Direct 2022; 8:e1322. [PMID: 35464875 PMCID: PMC9018997 DOI: 10.1097/txd.0000000000001322] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/22/2022] [Accepted: 03/15/2022] [Indexed: 11/27/2022] Open
Abstract
Quality in liver transplantation (LT) is currently measured using 1-y patient and graft survival. Because patient and graft survival rates now exceed 90%, more informative metrics are needed. Textbook outcomes (TOs) describe ideal patient outcomes after surgery. This study critically evaluates TO as a quality metric in LT.
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6
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Wallace D, Cowling TE, Walker K, Suddle A, Gimson A, Rowe I, Callaghan C, Heaton N, van der Meulen J, Bernal W. The Impact of Performance Status on Length of Hospital Stay and Clinical Complications Following Liver Transplantation. Transplantation 2021; 105:2037-2044. [PMID: 33044430 DOI: 10.1097/tp.0000000000003484] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Impaired pretransplant performance status (PS) is associated with chronic liver disease (CLD). We studied its impact on hospital length of stay (LOS), complications, and readmissions in the first year after liver transplantation. METHODS The Standard National Liver Transplant Registry was linked to a hospital administrative dataset, and all first-time liver transplant recipients with CLD aged ≥18 years in England were identified. A modified 3-level Eastern Cooperative Oncology Group score was used to assess PS. Linear- and logistic-fixed effect regression models were used to estimate the effect of specific posttransplant complications and readmissions in the first year after transplantation. RESULTS Six thousand nine hundred sixty-eight recipients were included. Impaired PS was associated with an increased LOS in the initial posttransplant period (comparing ECOG 1-3, adjusted difference 7.2 d; 95% confidence [CI], 4.8-9.6; P < 0.001) and in time spent on the ITU (adjusted difference 1.2 d; 95% CI, 0.4-2.0; P < 0.001). There was no significant association between ECOG status and total LOS of later admissions (adjusted difference, 2.5 d; 95% CI, -0.4-5.5; P = 0.23). Those with a poorer ECOG status had an increased incidence of renal failure (odds ratio, 1.5; 95% CI, 1.1-2.0; P = 0.004) and infection (odds ratio, 1.2; 95% CI, 1.1-1.4; P = 0.02) but not an increased incidence of readmission (odds ratio, 1.2; 95% CI, 0.9-1.5; P = 0.13). CONCLUSIONS In liver transplant recipients with CLD, impaired pretransplant PS is associated with prolonged LOS in the immediate posttransplant period but not with LOS of later admissions in the first year after transplantation. Impaired PS increased the risk of renal failure and infection.
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Affiliation(s)
- David Wallace
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Thomas E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kate Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Abid Suddle
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Alex Gimson
- The Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Ian Rowe
- Liver Unit, St James' Hospital and University of Leeds, Leeds, United Kingdom
- Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom
| | - Chris Callaghan
- Department of Transplantation, Renal Unit, Guy's Hospital, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - William Bernal
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
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7
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Menahem B, Dejardin O, Alves A, Launay L, Lubrano J, Duvoux C, Laurent A, Launoy AG. Socioeconomic Deprivation Does Not Impact Liver Transplantation Outcome for HCC: A Survival Analysis From a National Database. Transplantation 2021; 105:1061-1068. [PMID: 32541559 DOI: 10.1097/tp.0000000000003340] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND To investigate the value of European deprivation index (EDI) and hepatocellular carcinoma (HCC) characteristics and their relationships with outcome after liver transplantation (LT). METHODS Patients undergoing LT for HCC were included from a national database (from "Agence de la Biomédecine" between 2006 and 2016. Characteristics of the patients were blindly extracted from the database. Thus, EDI was calculated in 5 quintiles and prognosis factors of survival were determined according to a Cox model. RESULTS Among the 3865 included patients, 33.9% were in the fifth quintile (quintile 1, N = 562 [14.5%]; quintile 2, N = 647 [16.7%]; quintile 3, N = 654 [16.9%]; quintile 4, N = 688 [17.8%]). Patients in each quintile were comparable regarding HCC history, especially median size of HCC, number of nodules of HCC and alpha-fetoprotein score. In the univariate analysis of the crude survival, having >2 nodules of HCC before LT and time on waiting list were associated with a higher risk of death (P < 0.0001 and P = 0.03, respectively). EDI, size of HCC, model for end-stage liver disease score, Child-Pugh score were not statistically significant in the crude and net survival. In both survival, time on waiting list and number of HCC ≥2 were independent factor of mortality after LT for HCC (P = 0.009 and 0.001, respectively, and P = 0.03 and 0.02, respectively). CONCLUSIONS EDI does not impact overall survival after LT for HCC. Number of HCC and time on waiting list are independent prognostic factors of survival after LT for HCC.
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Affiliation(s)
- Benjamin Menahem
- Department of Digestive Surgery, CHU de Caen, Caen cedex, France
- Anticipe, INSERM U1086, Pôle de Recherche du CHU de Caen, Centre François Baclesse, Caen cedex, France
| | - Olivier Dejardin
- Anticipe, INSERM U1086, Pôle de Recherche du CHU de Caen, Centre François Baclesse, Caen cedex, France
- Department of Research, CHU de Caen, Caen cedex, France
| | - Arnaud Alves
- Department of Digestive Surgery, CHU de Caen, Caen cedex, France
- Anticipe, INSERM U1086, Pôle de Recherche du CHU de Caen, Centre François Baclesse, Caen cedex, France
| | - Ludivine Launay
- Anticipe, INSERM U1086, Pôle de Recherche du CHU de Caen, Centre François Baclesse, Caen cedex, France
| | - Jean Lubrano
- Department of Digestive Surgery, CHU de Caen, Caen cedex, France
- Anticipe, INSERM U1086, Pôle de Recherche du CHU de Caen, Centre François Baclesse, Caen cedex, France
| | - Christophe Duvoux
- Department of Hepatology, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Alexis Laurent
- Department of Hepatobiliary, Pancreatic Surgery and Liver Transplantation, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
- INSERM, UMR 955, Créteil, France
| | - And Guy Launoy
- Anticipe, INSERM U1086, Pôle de Recherche du CHU de Caen, Centre François Baclesse, Caen cedex, France
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8
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Ranganath NK, Malas J, Chen S, Smith DE, Chang SH, Lesko MB, Angel LF, Lonze BE, Kon ZN. High Lung Transplant Center Volume Is Associated With Increased Survival in Hospitalized Patients. Ann Thorac Surg 2020; 111:1652-1658. [PMID: 32950494 DOI: 10.1016/j.athoracsur.2020.06.124] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 05/28/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The lung allocation score (LAS) was designed to optimize the use of pulmonary allografts based on anticipated pretransplant survival and posttransplant outcome. Hospital admission status, not included in the LAS, has not been comprehensively investigated with regard to organ allocation. The objective of this study was to determine whether pretransplant hospital admission status was independently associated with posttransplant mortality and whether high center volume was associated with improved survival in that cohort. METHODS All consecutive adult lung transplants provided by the Scientific Registry of Transplant Recipients were retrospectively reviewed (from 2007 to 2017). Group stratification was performed based on admission status at the time of transplantation. A Cox proportional hazard regression was used to determine independent associations with posttransplant mortality. RESULTS During the study period, 3747 of 18,416 recipients (20%) were admitted to the hospital at the time of transplantation. Compared with nonadmitted recipients, LAS were significantly higher and waitlist times significantly shorter. Admitted recipients had higher rates of prolonged mechanical ventilation, higher rates of posttransplant dialysis, and longer posttransplant lengths of stay. Pretransplant admission to a low-volume center conferred significantly worse survival compared with nonadmitted patients, and high-volume centers were independently associated with improved survival compared with low-volume centers. CONCLUSIONS Hospital admission status is associated with increased posttransplant mortality independent of the LAS and the factors from which it is calculated. However, adjusted survival analysis demonstrates that admission to a high-volume center appears to be independently associated with improved survival compared with low-volume centers.
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Affiliation(s)
- Neel K Ranganath
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York.
| | - Jad Malas
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Stacey Chen
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Deane E Smith
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Stephanie H Chang
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Melissa B Lesko
- Department of Medicine, NYU Langone Health, New York, New York
| | - Luis F Angel
- Department of Medicine, NYU Langone Health, New York, New York
| | - Bonnie E Lonze
- Department of Surgery, Transplant Institute, NYU Langone Health, New York, New York
| | - Zachary N Kon
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
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9
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Artzner T, Michard B, Weiss E, Barbier L, Noorah Z, Merle JC, Paugam-Burtz C, Francoz C, Durand F, Soubrane O, Pirani T, Theocharidou E, O'Grady J, Bernal W, Heaton N, Salamé E, Bucur P, Barraud H, Lefebvre F, Serfaty L, Besch C, Bachellier P, Schneider F, Levesque E, Faitot F. Liver transplantation for critically ill cirrhotic patients: Stratifying utility based on pretransplant factors. Am J Transplant 2020; 20:2437-2448. [PMID: 32185866 DOI: 10.1111/ajt.15852] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/19/2020] [Accepted: 02/27/2020] [Indexed: 01/25/2023]
Abstract
The aim of this study was to produce a prognostic model to help predict posttransplant survival in patients transplanted with grade-3 acute-on-chronic liver failure (ACLF-3). Patients with ACLF-3 who underwent liver transplantation (LT) between 2007 and 2017 in 5 transplant centers were included (n = 152). Predictors of 1-year mortality were retrospectively screened and tested on a single center training cohort and subsequently tested on an independent multicenter cohort composed of the 4 other centers. Four independent pretransplant risk factors were associated with 1-year mortality after transplantation in the training cohort: age ≥53 years (P = .044), pre-LT arterial lactate level ≥4 mml/L (P = .013), mechanical ventilation with PaO2 /FiO2 ≤ 200 mm Hg (P = .026), and pre-LT leukocyte count ≤10 G/L (P = .004). A simplified version of the model was derived by assigning 1 point to each risk factor: the transplantation for Aclf-3 model (TAM) score. A cut-off at 2 points distinguished a high-risk group (score >2) from a low-risk group (score ≤2) with 1-year survival of 8.3% vs 83.9% respectively (P < .001). This model was subsequently validated in the independent multicenter cohort. The TAM score can help stratify posttransplant survival and identify an optimal transplantation window for patients with ACLF-3.
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Affiliation(s)
- Thierry Artzner
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Baptiste Michard
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Emmanuel Weiss
- Département Anesthésie et Réanimation, AP-HP, Hôpital Beaujon, Clichy, France.,UMR S 1149 Inserm/Université Paris Diderot, Paris, France
| | - Louise Barbier
- Service de Chirurgie Digestive et Transplantation Hépatique, CHU Trousseau, Université de Tours, Tours, France.,FHU SUPORT (Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation), Strasbourg, France
| | - Zair Noorah
- Service d'Anesthésie et Réanimation Chirurgicale, Hôpital Henri Mondor, Créteil, France
| | - Jean-Claude Merle
- Service d'Anesthésie et Réanimation Chirurgicale, Hôpital Henri Mondor, Créteil, France
| | - Catherine Paugam-Burtz
- Département Anesthésie et Réanimation, AP-HP, Hôpital Beaujon, Clichy, France.,UMR S 1149 Inserm/Université Paris Diderot, Paris, France
| | - Claire Francoz
- UMR S 1149 Inserm/Université Paris Diderot, Paris, France.,Département d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - François Durand
- UMR S 1149 Inserm/Université Paris Diderot, Paris, France.,Département d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Olivier Soubrane
- UMR S 1149 Inserm/Université Paris Diderot, Paris, France.,Service de Chirurgie Hépato-Pancréato-Biliaire, AP-HP Hôpital Beaujon, Clichy, France
| | - Tasneem Pirani
- Institute of Liver Studies, King's College Hospital, London, UK
| | | | - John O'Grady
- Institute of Liver Studies, King's College Hospital, London, UK
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Ephrem Salamé
- Service de Chirurgie Digestive et Transplantation Hépatique, CHU Trousseau, Université de Tours, Tours, France.,FHU SUPORT (Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation), Strasbourg, France
| | - Petru Bucur
- Service de Chirurgie Digestive et Transplantation Hépatique, CHU Trousseau, Université de Tours, Tours, France.,FHU SUPORT (Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation), Strasbourg, France
| | - Hélène Barraud
- FHU SUPORT (Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation), Strasbourg, France.,Service d'Hépatologie, CHU Trousseau, Université de Tours, France
| | - François Lefebvre
- Service de Santé Publique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Lawrence Serfaty
- Service d'Hépato-Gastro-Entérologie et d'Assistance Nutritive, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Camille Besch
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Philippe Bachellier
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Francis Schneider
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,UMR S 1121 Inserm/Université de Strasbourg, Strasbourg, France
| | - Eric Levesque
- Service d'Anesthésie et Réanimation Chirurgicale, Hôpital Henri Mondor, Créteil, France
| | - François Faitot
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Laboratoire ICube, UMR 7357, Université de Strasbourg, Strasbourg, France
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10
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Rubin JB, Cullaro G, Ge J, Lai JC. Women who undergo liver transplant have longer length of stay post-transplant compared with men. Liver Int 2020; 40:1725-1735. [PMID: 32412164 PMCID: PMC7968877 DOI: 10.1111/liv.14512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 02/13/2020] [Accepted: 05/07/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Women on the liver transplant waitlist are at greater risk of hospitalization compared with men, but whether this impacts length of stay (LOS) post-transplant is unknown. We aimed to evaluate gender disparities in post-transplant LOS, an important surrogate of health resource utilization post-transplant. METHODS Using the UNOS/OPTN registry, we analysed all non-Status 1 adult deceased donor liver transplant recipients without exception points from 2008 to 2017. Poisson regression associated female gender with post-transplant LOS. RESULTS Of 27 294 transplant recipients, 36% were women. Women were more likely to be hospitalized pretransplant than men (44% vs 39%, P < .01). Post-transplant, women were more likely to have prolonged (≥20d) LOS (25% vs 22%, P < .01). In univariable analysis, female gender was associated with longer post-transplant LOS (IRR 1.09, 95%CI 1.06-1.12, P < .01). Prolonged pretransplant admission was also associated with post-transplant LOS (IRR 1.83, 95%CI 1.77-1.89, P < .01). In multivariable analysis, female gender remained independently associated with post-transplant LOS (aIRR 1.05, 95%CI 1.02-1.08, P < .01), after adjustment for age, UNOS region, insurance type, MELDNa, cirrhosis complications, and donor risk index. Pretransplant hospitalization mediated this relationship, explaining 14.1% (95%CI 9.7%-25.4%) of the total effect. CONCLUSIONS Women who undergo deceased donor liver transplant have increased healthcare utilization in the peritransplant period compared with men. Reducing gender disparities in liver transplantation, including the disproportionate burden of healthcare utilization by women pre- and post-transplant, will require interventions targeted at preventing hospitalization among women on the transplant waitlist and developing tools aimed at better characterizing the severity of end-stage liver disease in women.
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Affiliation(s)
- Jessica B. Rubin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Giuseppe Cullaro
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY
| | - Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
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11
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Wiering L, Öllinger R, Kruppa J, Schoeneberg U, Dziodzio T, Jara M, Biebl M, Dargie R, Raschzok N, Schöning W, Eurich D, Schmelzle M, Sauer IM, Pratschke J, Ritschl PV. Hospitalization Before Liver Transplantation Predicts Posttransplant Patient Survival: A Propensity Score-Matched Analysis. Liver Transpl 2020; 26:628-639. [PMID: 32159923 DOI: 10.1002/lt.25748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 01/22/2020] [Accepted: 02/11/2020] [Indexed: 01/13/2023]
Abstract
In contrast to donor factors predicting outcomes of liver transplantation (LT), few suitable recipient parameters have been identified. To this end, we performed an in-depth analysis of hospitalization status and duration prior to LT as a potential risk factor for posttransplant outcome. The pretransplant hospitalization status of all patients undergoing LT between 2005 and 2016 at the Charité-Universitätsmedizin Berlin was analyzed retrospectively using propensity score matching. At the time of organ acceptance, 226 of 1134 (19.9%) recipients were hospitalized in an intensive care unit (ICU), 146 (12.9%) in a regular ward (RW) and 762 patients (67.2%) were at home. Hospitalized patients (RW and ICU) compared with patients from home showed a dramatically shorter 3-month survival (78.7% versus 94.4%), 1-year survival (66.3% versus 87.3%), and 3-year survival (61.7% versus 81.7%; all P < 0.001), whereas no significant difference was detected for 3-year survival between ICU and RW patients (61.5% versus 62.3%; P = 0.60). These results remained significant after propensity score matching. Furthermore, in ICU patients, but not in RW patients, survival correlated with days spent in the ICU before LT (1-year survival: 1-6 versus 7-14 days: 73.7% versus 60.5%, P = 0.04; 7-14 days versus >14 days, 60.5% versus 51.0%, P = 0.006). In conclusion, hospitalization status before transplantation is a valuable predictor of patient survival following LT.
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Affiliation(s)
- Leke Wiering
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen Kruppa
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Uwe Schoeneberg
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tomasz Dziodzio
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximillian Jara
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Biebl
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Richard Dargie
- Division of Emergency and Acute Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Charité Clinician Scientist Program, Berlin Institute of Health, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Dennis Eurich
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Igor M Sauer
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Paul V Ritschl
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Charité Clinician Scientist Program, Berlin Institute of Health, Berlin, Germany
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12
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Management of liver failure in general intensive care unit. Anaesth Crit Care Pain Med 2020; 39:143-161. [DOI: 10.1016/j.accpm.2019.06.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 06/30/2019] [Indexed: 12/11/2022]
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13
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Tomescu D, Popescu M, Biancofiore G. Liver transplantation for acute-on-chronic liver failure. Best Pract Res Clin Anaesthesiol 2019; 34:25-33. [PMID: 32334784 DOI: 10.1016/j.bpa.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 11/24/2022]
Abstract
Acute-on-chronic liver failure (AoCLF) represents a newly defined entity in patients with liver disease leading to multiple organ failures and increased mortality. To date, no universally accepted definition exists, and different academic societies developed guidelines on the early diagnosis and classification of AoCLF. Recently published trials focused on factors associated with a poor outcome and on the development of severity scores aimed to identify patients who may benefit for advanced monitoring and treatment. No specific therapies are demonstrated to improve survival, and liver transplantation (LT) remains the only treatment associated with improved outcome. Our review focuses on current evidence for early diagnosis and prognostication of disease in patients with AoCLF, as well of criteria for intensive care unit admission, indication, and futility markers of LT, as well as bridging therapy and optimal timing of surgery.
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Affiliation(s)
- Dana Tomescu
- "Carol Davila" University of Medicine and Pharmacy, Department of Anesthesiology and Critical Care, Bucharest, Romania; Fundeni Clinical Institute, Department of Anesthesiology and Critical Care III, Bucharest, Romania
| | - Mihai Popescu
- "Carol Davila" University of Medicine and Pharmacy, Department of Anesthesiology and Critical Care, Bucharest, Romania; Fundeni Clinical Institute, Department of Anesthesiology and Critical Care III, Bucharest, Romania.
| | - Gianni Biancofiore
- University School of Medicine, Department of Anesthesia and Critical Care, Pisa, Italy
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14
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Wu T, Sundaram V. Transplantation for Acute-on-Chronic Liver Failure. Clin Liver Dis (Hoboken) 2019; 14:152-155. [PMID: 31709045 PMCID: PMC6832096 DOI: 10.1002/cld.852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 06/07/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Tiffany Wu
- Department of Internal MedicineCedars‐Sinai Medical CenterLos AngelesCA
| | - Vinay Sundaram
- Department of Gastroenterology and Comprehensive Transplant CenterCedars‐Sinai Medical CenterLos AngelesCAUSA
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15
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Eman P, Chacon E, Gupta M, Berger JC, Shah MB, El Haddad HE, El-Husseini A, Dela Cruz AC, Grigorian A, Mei X, Gedaly R. Long term outcomes of patients transplanted for hepatocellular carcinoma with human immunodeficiency virus infection. HPB (Oxford) 2019; 21:1009-1016. [PMID: 30765199 DOI: 10.1016/j.hpb.2019.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/18/2018] [Accepted: 01/03/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND We aimed to study outcomes in HIV + patients with HCC in the US following Liver Transplantation (LT) using the UNOS dataset. METHODS The database was queried from 2003 to 2016 for patients undergoing LT with HCC, HIV+, and HCC/HIV+. RESULTS Out of 17,397 LT performed for HCC during the study period, 113 were transplanted for HCC with HIV infection (91 isolated livers). Patients transplanted for HCC/HIV+ were younger (55.54 ± 5.89 vs 58.80 ± 7.37, p < 0.001), had lower total bilirubin (1.20 vs 1.60, p = 0.042) significantly lower BMI (25.35 ± 4.43 vs 28.39 ± 5.17, p < 0.001) and were more likely to be co-infected with HBV (25.3% vs 8.2% p < 0.001) than those transplanted for HCC alone. HCC/HIV + patients were found to have a 3.8 fold increased risk of peri-operative mortality at 90 days after matching. HCC/HIV + recipients had 54% decreased long-term survival within the HCC cohort. Our initial analysis of overall graft and patient survival found significant differences between HCC/HIV and HCC/HIV + recipients. However, these variances were lost after case-matching. Recurrence and disease free survival were similar in HCC alone vs HCC/HIV + recipients. CONCLUSIONS Our analysis suggests that excellent outcomes can be achieved in selected patients with HCC/HIV+.
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Affiliation(s)
- Pedro Eman
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Eduardo Chacon
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Meera Gupta
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Jonathan C Berger
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Malay B Shah
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Hanine E El Haddad
- Department of Medicine, Division of Infectious Diseases, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Amr El-Husseini
- Department of Medicine, Division of Nephrology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Anna C Dela Cruz
- Department of Medicine, Division of Gastroenterology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Alla Grigorian
- Department of Medicine, Division of Gastroenterology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Xiaonan Mei
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Roberto Gedaly
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA.
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16
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Pre-Operative Delta-MELD is an Independent Predictor of Higher Mortality following Liver Transplantation. Sci Rep 2019; 9:8312. [PMID: 31165776 PMCID: PMC6549161 DOI: 10.1038/s41598-019-44814-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 05/14/2019] [Indexed: 12/13/2022] Open
Abstract
Clinical decompensation immediately prior to liver transplantation may affect post-liver transplant (LT) outcomes. Using the serial Model for End-Stage Liver Disease (MELD) scores recorded in the United Network for Organ Sharing national registry (2010-2017), we analyzed post-LT mortality among adult LT recipients based on the degree of fluctuation in MELD score during the 30-day period prior to LT surgery. Delta-MELD (D-MELD) was defined as recipient MELD score at LT minus lowest MELD score within the preceding 30 days. Impact of D-MELD as a continuous and categorical variable (D-MELD 0-4, 5-10, >10) on early, 30-day post-LT mortality was assessed. Overall, a total of 12,785 LT recipients were analyzed, of which 8,862 (67.9%) had a pre-operative D-MELD 0-4; 2,574 (20.1%) with a D-MELD 5-10; and 1,529 (12.0%) with a D-MELD > 10. One-point incremental increase in pre-operative D-MELD (adjusted HR, 1.07, 95% CI: 1.04-1.10) was associated with higher 30-day post-LT mortality. Moreover, pre-operative D-MELD > 10 was associated with nearly a two-fold increased risk for 30-day post-LT mortality (adjusted HR, 1.89, 95% CI: 1.30-2.77) compared to D-MELD 0-4. The increased risk of pre-LT mortality associated with severity of clinical decompensation assessed by the magnitude of pre-operative D-MELD persists in the early post-LT period.
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17
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Jasseron C, Francoz C, Antoine C, Legeai C, Durand F, Dharancy S. Impact of the new MELD-based allocation system on waiting list and post-transplant survival - a cohort analysis using the French national CRISTAL database. Transpl Int 2019; 32:1061-1073. [PMID: 31074921 DOI: 10.1111/tri.13448] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Concerns related to equity and efficacy of our previous center-based allocation system have led us to introduce a patient-based allocation system called the "Liver Score" that incorporates the MELD score. The main objective of this study was to compare waitlist and post-transplant survivals before and after implementation of the "Liver Score" using the French transplant registry (period before: 2004-2006 and period after: 2007-2012). Patients transplanted during the second period were sicker and had a higher MELD. One-year waitlist survival (74% versus 76%; p=0.8) and one-year post-transplant survival (86.3% vs 85.7%; p=0.5) were similar between the 2 periods. Cirrhotic recipients with MELD>35 had lower one-year post-transplant survival compared to those with MELD<35 (74.8% vs 86.3%; p<0.01), mainly explained by their higher intubation and renal failure rates. The MELD showed a poor discriminative capacity. In cirrhotic recipients with MELD>35, patients presenting 2 or 3 risk factors (dialysis, intubation or infection) had a lower 1-year survival compared to those with none of these risk factors (61.2% vs 92%; p<0.01). The implementation of the MELD-based allocation system has led to transplant sicker patients with no impact on waitlist and post-transplant survivals. Nevertheless, selection of patients with MELD>35 should be completed to allow safe transplantation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Carine Jasseron
- Agence de la biomédecine, direction prélèvement greffe organes-tissus, pôle évaluation, 93212, Saint-Denis La Plaine, cedex, France
| | - Claire Francoz
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France; INSERM U773, Centre de Recherche Biomédicale Bichat Beaujon CRB3France
| | - Corinne Antoine
- Agence de la biomédecine, direction générale médicale et scientifique, direction prélèvement greffe organes-tissus, pôle stratégie prélèvement greffe, 93212, Saint-Denis-la-Plaine cedex, France
| | - Camille Legeai
- Agence de la biomédecine, direction prélèvement greffe organes-tissus, pôle évaluation, 93212, Saint-Denis La Plaine, cedex, France
| | - François Durand
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France; INSERM U773, Centre de Recherche Biomédicale Bichat Beaujon CRB3France
| | - Sébastien Dharancy
- Inserm, UMR995 - LIRIC, Lille, France Univ Lille, UMR995 - LIRIC, Lille, France CHRU Lille, Service des Maladies de l'Appareil Digestif et de la Nutrition, Hôpital HuriezLille, France
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18
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Artru F, Samuel D. Approaches for patients with very high MELD scores. JHEP Rep 2019; 1:53-65. [PMID: 32039352 PMCID: PMC7001538 DOI: 10.1016/j.jhepr.2019.02.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/31/2019] [Accepted: 02/04/2019] [Indexed: 02/08/2023] Open
Abstract
In the era of the "sickest first" policy, patients with very high model for end-stage liver disease (MELD) scores have been increasingly admitted to the intensive care unit with the expectation that they will receive a liver transplant (LT) in the absence of improvement on supportive therapies. Such patients are often admitted in a context of acute-on-chronic liver failure with extrahepatic failures. Sequential assessment of scores or classification based on organ failures within the first days after admission help to stratify the risk of mortality in this population. Although the prognosis of severely ill cirrhotic patients has recently improved, transplant-free mortality remains high. LT is still the only curative treatment in this population. Yet, the increased relative scarcity of graft resource must be considered alongside the increased risk of losing a graft in the initial postoperative period when performing LT in "too sick to transplant" patients. Variables associated with poor immediate post-LT outcomes have been identified in large studies. Despite this, the performance of scores based on these variables is still insufficient. Consideration of a patient's comorbidities and frailty is an appealing predictive approach in this population that has proven of great value in many other diseases. So far, local expertise remains the last safeguard to LT. Using this expertise, data are accumulating on favourable post-LT outcomes in very high MELD populations, particularly when LT is performed in a situation of stabilization/improvement of organ failures in selected candidates. The absence of "definitive" contraindications and the control of "dynamic" contraindications allow a "transplantation window" to be defined. This window must be identified swiftly after admission given the poor short-term survival of patients with very high MELD scores. In the absence of any prospect of LT, withdrawal of care could be discussed to ensure respect of patient life, dignity and wishes.
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Affiliation(s)
- Florent Artru
- Liver Unit, CHRU Lille, France, University of Lille, LIRIC team, Inserm unit 995
| | - Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Villejuif, F-94800, France; Univ Paris-Sud, UMR-S 1193, Université Paris-Saclay, Villejuif, F-94800, France; Inserm, Unité 1193, Université Paris-Saclay, Villejuif, F-94800, France; Hepatinov, Villejuif, F-94800, France
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19
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Radosa CG, Radosa JC, Grosche-Schlee S, Zöphel K, Plodeck V, Kühn JP, Kotzerke J, Hoffmann RT. Holmium-166 Radioembolization in Hepatocellular Carcinoma: Feasibility and Safety of a New Treatment Option in Clinical Practice. Cardiovasc Intervent Radiol 2019; 42:405-412. [PMID: 30603976 DOI: 10.1007/s00270-018-2133-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 11/22/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE To investigate clinical feasibility, technical success and toxicity of 166Ho-radioembolization (166Ho-RE) as new approach for treatment of hepatocellular carcinomas (HCC) and to assess postinterventional calculation of exact dosimetry through quantitative analysis of MR images. MATERIALS AND METHODS From March 2017 to April 2018, nine patients suffering from HCC were treated with 166Ho-RE. To calculate mean doses on healthy liver/tumor tissue, MR was performed within the first day after treatment. For evaluation of hepatotoxicity and to rule out radioembolization-induced liver disease (REILD), the Model for End-Stage Liver Disease (MELD) Score, the Common Terminology Criteria for Adverse Events and specific laboratory parameters were used 1-day pre- and posttreatment and after 60 days. After 6 months, MR/CT follow-up was performed. RESULTS In five patients the right liver lobe, in one patient the left liver lobe and in three patients both liver lobes were treated. Median administered activity was 3.7 GBq (range 1.7-5.9 GBq). Median dose on healthy liver tissue was 41 Gy (21-55 Gy) and on tumor tissue 112 Gy (61-172 Gy). Four patients suffered from mild postradioembolization syndrome. No significant differences in median MELD-Score were observed pre-, posttherapeutic and 60 days after 166Ho-RE. No deterioration of liver function and no indicators of REILD were observed. One patient showed a complete response, four a partial response, three a stable disease and one a progressive disease at the 6 months follow-up. CONCLUSION 166Ho-RE seems to be a feasible and safe treatment option with no significant hepatotoxicity for treatment of HCC.
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Affiliation(s)
- Christoph G Radosa
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Julia C Radosa
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrbergerstraße 100, 66421, Homburg, Germany
| | - Sabine Grosche-Schlee
- Department of Nuclear Medicine, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Klaus Zöphel
- Department of Nuclear Medicine, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Verena Plodeck
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Jens P Kühn
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Jörg Kotzerke
- Department of Nuclear Medicine, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
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20
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Artzner T, Michard B, Besch C, Levesque E, Faitot F. Liver transplantation for critically ill cirrhotic patients: Overview and pragmatic proposals. World J Gastroenterol 2018; 24:5203-5214. [PMID: 30581269 PMCID: PMC6295835 DOI: 10.3748/wjg.v24.i46.5203] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation for critically ill cirrhotic patients with acute deterioration of liver function associated with extrahepatic organ failures is controversial. While transplantation has been shown to be beneficial on an individual basis, the potentially poorer post-transplant outcome of these patients taken as a group can be held as an argument against allocating livers to them. Although this issue concerns only a minority of liver transplants, it calls into question the very heart of the allocation paradigms in place. Indeed, most allocation algorithms have been centered on prioritizing the sickest patients by using the model for end-stage liver disease score. This has led to allocating increasing numbers of livers to increasingly critically ill patients without setting objective or consensual limits on how sick patients can be when they receive an organ. Today, finding robust criteria to deem certain cirrhotic patients too sick to be transplanted seems urgent in order to ensure the fairness of our organ allocation protocols. This review starts by fleshing out the argument that finding such criteria is essential. It examines five types of difficulties that have hindered the progress of recent literature on this issue and identifies various strategies that could be followed to move forward on this topic, taking into account the recent discussion on acute on chronic liver failure. We move on to review the literature along four axes that could guide clinicians in their decision-making process regarding transplantation of critically ill cirrhotic patients.
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Affiliation(s)
- Thierry Artzner
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
| | - Baptiste Michard
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
| | - Camille Besch
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
| | - Eric Levesque
- Service d’Anesthésie et Réanimation Chirurgicale, Hôpital Henri Mondor, Créteil 94000, France
| | - François Faitot
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
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21
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Sun Z, Chang B, Huang A, Hao S, Gao M, Sun Y, Shi M, Jin L, Zhang W, Zhao J, Teng G, Han L, Tian H, Liang Q, Zhang JY, Zou Z. Plasma levels of soluble ST2, but not IL-33, correlate with the severity of alcoholic liver disease. J Cell Mol Med 2018; 23:887-897. [PMID: 30478965 PMCID: PMC6349182 DOI: 10.1111/jcmm.13990] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/08/2018] [Indexed: 12/14/2022] Open
Abstract
Alcoholic liver disease (ALD) is a complication that is a burden on global health and economy. Interleukin‐33 (IL‐33) is a newly identified member of the IL‐1 cytokine family and is released as an “alarmin” during inflammation. Soluble suppression of tumourigenicity 2 (sST2), an IL‐33 decoy receptor, has been reported as a new biomarker for the severity of systemic and highly inflammatory diseases. Here, we found the levels of plasma sST2, increased with the disease severity from mild to severe ALD. Importantly, the plasma sST2 levels in ALD patients not only correlated with scores for prognostic models (Maddrey's discriminant function, model for end‐stage liver disease and Child‐Pugh scores) and indexes for liver function (total bilirubin, international normalized ratio, albumin, and cholinesterase) but also correlated with neutrophil‐associated factors as well as some proinflammatory cytokines. In vitro, lipopolysaccharide‐activated monocytes down‐regulated transmembrane ST2 receptor but up‐regulated sST2 mRNA and protein expression and produced higher levels of tumour necrosis factor‐α (TNF‐α). By contrast, monocytes pretreated with recombinant sST2 showed decreased TNF‐α production. In addition, although plasma IL‐33 levels were comparable between healthy controls and ALD patients, we found the IL‐33 expression in liver tissues from ALD patients was down‐regulated at both RNA and protein levels. Immunohistochemical staining further showed that the decreased of IL‐33‐positive cells were mainly located in liver lobule area. These results suggested that sST2, but not IL‐33, is closely related to the severity of ALD. Consequently, sST2 could be used as a potential biomarker for predicting the prognosis of ALD.
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Affiliation(s)
- Zijian Sun
- Center of Non-infectious Liver Diseases, Peking University 302 Clinical Medical School, Beijing, China
| | - Binxia Chang
- Center of Non-infectious Liver Diseases, Beijing 302 Hospital, Beijing, China
| | - Ang Huang
- Center of Non-infectious Liver Diseases, Beijing 302 Hospital, Beijing, China
| | - Shuli Hao
- Center of Non-infectious Liver Diseases, Beijing 302 Hospital, Beijing, China
| | - Miaomiao Gao
- Center of Non-infectious Liver Diseases, Peking University 302 Clinical Medical School, Beijing, China
| | - Ying Sun
- Center of Non-infectious Liver Diseases, Beijing 302 Hospital, Beijing, China
| | - Ming Shi
- Treatment and Research Center for Infectious Diseases, Beijing 302 Hospital, Beijing, China
| | - Lei Jin
- Treatment and Research Center for Infectious Diseases, Beijing 302 Hospital, Beijing, China
| | - Wei Zhang
- Center of Non-infectious Liver Diseases, Beijing 302 Hospital, Beijing, China
| | - Jun Zhao
- Center of Non-infectious Liver Diseases, Beijing 302 Hospital, Beijing, China
| | - Guangju Teng
- Center of Non-infectious Liver Diseases, Beijing 302 Hospital, Beijing, China
| | - Lin Han
- Center of Non-infectious Liver Diseases, Beijing 302 Hospital, Beijing, China
| | - Hui Tian
- Center of Non-infectious Liver Diseases, Beijing 302 Hospital, Beijing, China
| | - Qingsheng Liang
- Center of Non-infectious Liver Diseases, Beijing 302 Hospital, Beijing, China
| | - Ji-Yuan Zhang
- Treatment and Research Center for Infectious Diseases, Beijing 302 Hospital, Beijing, China
| | - Zhengsheng Zou
- Center of Non-infectious Liver Diseases, Peking University 302 Clinical Medical School, Beijing, China
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22
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Bajaj JS, Moreau R, Kamath PS, Vargas HE, Arroyo V, Reddy KR, Szabo G, Tandon P, Olson J, Karvellas C, Gustot T, Lai JC, Wong F. Acute-on-Chronic Liver Failure: Getting Ready for Prime Time? Hepatology 2018; 68:1621-1632. [PMID: 29689120 DOI: 10.1002/hep.30056] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/19/2018] [Indexed: 02/06/2023]
Abstract
UNLABELLED Acute on chronic liver failure (ACLF) is the culmination of chronic liver disease and extrahepatic organ failures, which is associated with a high short-term mortality and immense health care expenditure. There are varying definitions for organ failures and ACLF in Europe, North America, and Asia. These differing definitions need to be reconciled to enhance progress in the field. The pathogenesis of ACLF is multifactorial and related to interactions between the immunoinflammatory system, microbiota, and the various precipitating factors. Individual organ failures related to the kidney, brain, lungs, and circulation have cumulative adverse effects on mortality and are often complicated or precipitated by infections. Strategies to prevent and rapidly treat these organ failures are paramount in improving survival. With the aging population and paucity of organs for liver transplant, the prognosis of ACLF patients is poor, highlighting the need for novel therapeutic strategies. The role of liver transplant in ACLF is evolving and needs further investigation across large consortia. A role for early palliative care and management of frailty as approaches to alleviate disease burden and improve patient-reported outcomes is being increasingly recognized. CONCLUSION ACLF is a clinically relevant syndrome that is epidemic worldwide and requires a dedicated multinational approach focused on prognostication and management; investigations are underway worldwide to prepare ACLF for prime time. (Hepatology 2018; 00:000-000).
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Affiliation(s)
- Jasmohan S Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Richard Moreau
- INSERM, Université Paris Diderot-Paris 7, Centre de Recherche sur l'Inflammation, Paris, France; Département Hospitalo-Universitaire UNITY, Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
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Singanayagam A, Bernal W. Transplantation for the Very Sick Patient—Donor and Recipient Factors. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0197-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Bittermann T, Hubbard RA, Serper M, Lewis JD, Hohmann SF, VanWagner LB, Goldberg DS. Healthcare utilization after liver transplantation is highly variable among both centers and recipients. Am J Transplant 2018; 18:1197-1205. [PMID: 29024364 PMCID: PMC5895535 DOI: 10.1111/ajt.14539] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/26/2017] [Accepted: 10/03/2017] [Indexed: 01/25/2023]
Abstract
The relationship between healthcare utilization before and after liver transplantation (LT), and its association with center characteristics, is incompletely understood. This was a retrospective cohort study of 34 402 adult LTs between 2002 and 2013 using Vizient inpatient claims data linked to the United Network for Organ Sharing (UNOS) database. Multivariable mixed-effects linear regression models evaluated the association between hospitalization 90 days pre-LT and the number of days alive and out of the hospital (DAOH) 1 year post-LT. Of those patients alive at LT discharge, 24.7% spent ≥30 days hospitalized during the first year. Hospitalization in the 90 days pre-LT was inversely associated with DAOH (β = -3.4 DAOH/week hospitalized pre-LT; P = .002). Centers with >30% of their liver transplant recipients hospitalized ≥30 days in the first LT year were typically smaller volume and/or transplanting higher risk recipients (Model for End-Stage Liver Disease [MELD] score ≥35, inpatient or ventilated pre-LT). In conclusion, pre-LT hospitalization predicts 1-year post-LT hospitalization independent of MELD score at the patient-level, whereas center-specific post-LT healthcare utilization is associated with certain center behaviors and selection practices.
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Affiliation(s)
- T Bittermann
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - R A Hubbard
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - M Serper
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - J D Lewis
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - S F Hohmann
- Center for Advanced Analytics, Vizient, Chicago, IL, USA
| | - L B VanWagner
- Division of Gastroenterology & Hepatology and Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
| | - D S Goldberg
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
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25
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Serper M, Bittermann T, Rossi M, Goldberg DS, Thomasson AM, Olthoff KM, Shaked A. Functional status, healthcare utilization, and the costs of liver transplantation. Am J Transplant 2018; 18:1187-1196. [PMID: 29116679 DOI: 10.1111/ajt.14576] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 10/30/2017] [Accepted: 10/30/2017] [Indexed: 01/25/2023]
Abstract
The Model for End-Stage Liver Disease (MELD) score predicts higher transplant healthcare utilization and costs; however, the independent contribution of functional status towards costs is understudied. The study objective was to evaluate the association between functional status, as measured by Karnofsky Performance Status (KPS), and liver transplant (LT) costs in the first posttransplant year. In a cohort of 598 LT recipients from July 1, 2009 to November 30, 2014, multivariable models assessed associations between KPS and outcomes. LT recipients needing full assistance (KPS 10%-40%) vs being independent (KPS 80%-100%) were more likely to be discharged to a rehabilitation facility after LT (22% vs 3%) and be rehospitalized within the first posttransplant year (78% vs 57%), all P < .001. In adjusted generalized linear models, in addition to MELD (P < .001), factors independently associated with higher 1-year post-LT transplant costs were older age, poor functional status (KPS 10%-40%), living donor LT, pre-LT hemodialysis, and the donor risk index (all P < .001). One-year survival for patients in the top cost decile was 83% vs 93% for the rest of the cohort (log rank P < .001). Functional status is an important determinant of posttransplant resource utilization; therefore, standardized measurements of functional status should be considered to optimize candidate selection and outcomes.
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Affiliation(s)
- Marina Serper
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Therese Bittermann
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Rossi
- Corporate Finance, Decision Support & Reimbursement, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - David S Goldberg
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Arwin M Thomasson
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kim M Olthoff
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Abraham Shaked
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA, USA
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26
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Andres A, Montano-Loza A, Greiner R, Uhlich M, Jin P, Hoehn B, Bigam D, Shapiro JAM, Kneteman NM. A novel learning algorithm to predict individual survival after liver transplantation for primary sclerosing cholangitis. PLoS One 2018; 13:e0193523. [PMID: 29543895 PMCID: PMC5854273 DOI: 10.1371/journal.pone.0193523] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 02/13/2018] [Indexed: 12/18/2022] Open
Abstract
Deciding who should receive a liver transplant (LT) depends on both urgency and utility. Most survival scores are validated through discriminative tests, which compare predicted outcomes between patients. Assessing post-transplant survival utility is not discriminate, but should be “calibrated” to be effective. There are currently no such calibrated models. We developed and validated a novel calibrated model to predict individual survival after LT for Primary Sclerosing Cholangitis (PSC). We applied a software tool, PSSP, to adult patients in the Scientific Registry of Transplant Recipients (n = 2769) who received a LT for PSC between 2002 and 2013; this produced a model for predicting individual survival distributions for novel patients. We also developed an appropriate evaluation measure, D-calibration, to validate this model. The learned PSSP model showed an excellent D-calibration (p = 1.0), and passed the single-time calibration test (Hosmer-Lemeshow p-value of over 0.05) at 0.25, 1, 5 and 10 years. In contrast, the model based on traditional Cox regression showed worse calibration on long-term survival and failed at 10 years (Hosmer-Lemeshow p value = 0.027). The calculator and visualizer are available at: http://pssp.srv.ualberta.ca/calculator/liver_transplant_2002. In conclusion we present a new tool that accurately estimates individual post liver transplantation survival.
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Affiliation(s)
- Axel Andres
- Transplantation Surgery, Dept of Surgery, University of Alberta Hospital, Edmonton, Alberta, Canada
- Visceral Surgery and Transplantation, Dept of Surgery, Geneva University Hospital, Geneva, Switzerland
- * E-mail:
| | - Aldo Montano-Loza
- Alberta Transplant Institute, University of Alberta, Edmonton, Alberta, Canada
- Hepatology, Dept of Medicine, University of Alberta Hospital, Edmonton, Canada
| | - Russell Greiner
- Dept of Computing Science, University of Alberta, Edmonton, Canada
- Alberta Innovates Centre for Machine Learning, Edmonton, Canada
| | - Max Uhlich
- Alberta Innovates Centre for Machine Learning, Edmonton, Canada
| | - Ping Jin
- Dept of Computing Science, University of Alberta, Edmonton, Canada
| | - Bret Hoehn
- Alberta Innovates Centre for Machine Learning, Edmonton, Canada
| | - David Bigam
- Transplantation Surgery, Dept of Surgery, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - James Andrew Mark Shapiro
- Transplantation Surgery, Dept of Surgery, University of Alberta Hospital, Edmonton, Alberta, Canada
- Visceral Surgery and Transplantation, Dept of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Norman Mark Kneteman
- Transplantation Surgery, Dept of Surgery, University of Alberta Hospital, Edmonton, Alberta, Canada
- Visceral Surgery and Transplantation, Dept of Surgery, Geneva University Hospital, Geneva, Switzerland
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27
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Liver transplantation in the most severely ill cirrhotic patients: A multicenter study in acute-on-chronic liver failure grade 3. J Hepatol 2017. [PMID: 28645736 DOI: 10.1016/j.jhep.2017.06.009] [Citation(s) in RCA: 246] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Liver transplantation (LT) for the most severely ill patients with cirrhosis, with multiple organ dysfunction (accurately assessed by the acute-on-chronic liver failure [ACLF] classification) remains controversial. We aimed to report the results of LT in patients with ACLF grade 3 and to compare these patients to non-transplanted patients with cirrhosis and multiple organ dysfunction as well as to patients transplanted with lower ACLF grade. METHODS All patients with ACLF-3 transplanted in three liver intensive care units (ICUs) were retrospectively included. Each patient with ACLF-3 was matched to a) non-transplanted patients hospitalized in the ICU with multiple organ dysfunction, or b) control patients transplanted with each of the lower ACLF grades (three groups). RESULTS Seventy-three patients were included. These severely ill patients were transplanted following management to stabilize their condition with a median of nine days after admission (progression of mean organ failure from 4.03 to 3.67, p=0.009). One-year survival of transplanted patients with ACLF-3 was higher than that of non-transplanted controls: 83.9 vs. 7.9%, p<0.0001. This high survival rate was not different from that of matched control patients with no ACLF (90%), ACLF-1 (82.3%) or ACLF-2 (86.2%). However, a higher rate of complications was observed (100 vs. 51.2 vs. 76.5 vs. 74.3%, respectively), with a longer hospital stay. The notion of a "transplantation window" is discussed. CONCLUSIONS LT strongly influences the survival of patients with cirrhosis and ACLF-3 with a 1-year survival similar to that of patients with a lower grade of ACLF. A rapid decision-making process is needed because of the short "transplantation window" suggesting that patients with ACLF-3 should be rapidly referred to a specific liver ICU. Lay summary: Liver transplantation improves survival of patients with very severe cirrhosis. These patients must be carefully monitored and managed in a specialized unit. The decision to transplant a patient must be quick to avoid a high risk of mortality.
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Bernal W. Improving outcomes for transplantation of critically ill patients with cirrhosis? Clin Liver Dis (Hoboken) 2017; 10:25-28. [PMID: 30992754 PMCID: PMC6467230 DOI: 10.1002/cld.646] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/14/2017] [Accepted: 05/20/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- William Bernal
- Liver Intensive Therapy Unit, Institute of Liver StudiesKings College HospitalLondonUnited Kingdom
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29
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Weil D, Levesque E, McPhail M, Cavallazzi R, Theocharidou E, Cholongitas E, Galbois A, Pan HC, Karvellas CJ, Sauneuf B, Robert R, Fichet J, Piton G, Thevenot T, Capellier G, Di Martino V. Prognosis of cirrhotic patients admitted to intensive care unit: a meta-analysis. Ann Intensive Care 2017; 7:33. [PMID: 28321803 PMCID: PMC5359266 DOI: 10.1186/s13613-017-0249-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/18/2017] [Indexed: 02/08/2023] Open
Abstract
Background The best predictors of short- and medium-term mortality of cirrhotic patients receiving intensive care support are unknown. Methods We conducted meta-analyses from 13 studies (2523 cirrhotics) after selection of original articles and response to a standardized questionnaire by the corresponding authors. End-points were in-ICU, in-hospital, and 6-month mortality in ICU survivors. A total of 301 pooled analyses, including 95 analyses restricted to 6-month mortality among ICU survivors, were conducted considering 249 variables (including reason for admission, organ replacement therapy, and composite prognostic scores). Results In-ICU, in-hospital, and 6-month mortality was 42.7, 54.1, and 75.1%, respectively. Forty-eight patients (3.8%) underwent liver transplantation during follow-up. In-ICU mortality was lower in patients admitted for variceal bleeding (OR 0.46; 95% CI 0.36–0.59; p < 0.001) and higher in patients with SOFA > 19 at baseline (OR 8.54; 95% CI 2.09–34.91; p < 0.001; PPV = 0.93). High SOFA no longer predicted mortality at 6 months in ICU survivors. Twelve variables related to infection were predictors of in-ICU mortality, including SIRS (OR 2.44; 95% CI 1.64–3.65; p < 0.001; PPV = 0.57), pneumonia (OR 2.18; 95% CI 1.47–3.22; p < 0.001; PPV = 0.69), sepsis-associated refractory oliguria (OR 10.61; 95% CI 4.07–27.63; p < 0.001; PPV = 0.76), and fungal infection (OR 4.38; 95% CI 1.11–17.24; p < 0.001; PPV = 0.85). Among therapeutics, only dopamine (OR 5.57; 95% CI 3.02–10.27; p < 0.001; PPV = 0.68), dobutamine (OR 8.92; 95% CI 3.32–23.96; p < 0.001; PPV = 0.86), epinephrine (OR 5.03; 95% CI 2.68–9.42; p < 0.001; PPV = 0.77), and MARS (OR 2.07; 95% CI 1.22–3.53; p = 0.007; PPV = 0.58) were associated with in-ICU mortality without heterogeneity. In ICU survivors, eight markers of liver and renal failure predicted 6-month mortality, including Child–Pugh stage C (OR 2.43; 95% CI 1.44–4.10; p < 0.001; PPV = 0.57), baseline MELD > 26 (OR 3.97; 95% CI 1.92–8.22; p < 0.0001; PPV = 0.75), and hepatorenal syndrome (OR 4.67; 95% CI 1.24–17.64; p = 0.022; PPV = 0.88). Conclusions Prognosis of cirrhotic patients admitted to ICU is poor since only a minority undergo liver transplant. The prognostic performance of general ICU scores decreases over time, unlike the Child–Pugh and MELD scores, even recorded in the context of organ failure. Infection-related parameters had a short-term impact, whereas liver and renal failure had a sustained impact on mortality. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0249-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Delphine Weil
- Hepatology Department, University Hospital Jean Minjoz, 3 bld Fleming, 25030, Besançon, France
| | - Eric Levesque
- Centre Hépato-Biliaire, University Hospital Paul Brousse, Villejuif, France
| | - Marc McPhail
- Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College Hospital, London, UK
| | | | - Eleni Theocharidou
- Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
| | | | - Arnaud Galbois
- Intensive Care Unit, University Hospital Saint-Antoine, Paris, France
| | - Heng Chih Pan
- Nephrology Department, Chang Gung Memorial Hospital, Taipei, Taiwan
| | | | | | - René Robert
- Intensive Care Unit, University Hospital of Poitiers, Poitiers, France
| | - Jérome Fichet
- Intensive Care Unit, University Hospital of Tours, Tours, France
| | - Gaël Piton
- Intensive Care Unit, University Hospital Jean Minjoz, Besançon, France
| | - Thierry Thevenot
- Hepatology Department, University Hospital Jean Minjoz, 3 bld Fleming, 25030, Besançon, France
| | - Gilles Capellier
- Intensive Care Unit, University Hospital Jean Minjoz, Besançon, France
| | - Vincent Di Martino
- Hepatology Department, University Hospital Jean Minjoz, 3 bld Fleming, 25030, Besançon, France.
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Ling Q, Dai H, Zhuang R, Shen T, Wang W, Xu X, Zheng S. Predicting short-term survival after liver transplantation on eight score systems: a national report from China Liver Transplant Registry. Sci Rep 2017; 7:42253. [PMID: 28198820 PMCID: PMC5304182 DOI: 10.1038/srep42253] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 01/08/2017] [Indexed: 12/16/2022] Open
Abstract
To compare the performance of eight score systems (MELD, uMELD, MELD-Na. iMELD, UKELD, MELD-AS, CTP, and mCTP) in predicting the post-transplant mortality, we analyzed the data of 6,014 adult cirrhotic patients who underwent liver transplantation between January 2003 and December 2010 from the China Liver Transplant Registry database. In hepatitis B virus (HBV) group, MELD, uMELD and MELD-AS showed good predictive accuracies at 3-month mortality after liver transplantation; by comparison with other five models, MELD presented the best ability in predicting 3-month, 6-month and 1-year mortality, showing a significantly better predictive ability than UKELD and iMELD. In hepatitis C virus and Alcohol groups, the predictive ability did not differ significantly between MELD and other models. Patient survivals in different MELD categories were of statistically significant difference. Among patients with MELD score >35, a new prognostic model based on serum creatinine, need for hemodialysis and moderate ascites could identify the sickest one. In conclusion, MELD is superior to other score systems in predicting short-term post-transplant survival in patients with HBV-related liver disease. Among patients with MELD score >35, a new prognostic model can identify the sickest patients who should be excluded from waiting list to prevent wasteful transplantation.
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Affiliation(s)
- Qi Ling
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haojiang Dai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Runzhou Zhuang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tian Shen
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weilin Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative innovation center for diagnosis and treatment of infectious diseases, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Pretransplant Factors and Associations with Postoperative Respiratory Failure, ICU Length of Stay, and Short-Term Survival after Liver Transplantation in a High MELD Population. J Transplant 2016; 2016:6787854. [PMID: 27980860 PMCID: PMC5131244 DOI: 10.1155/2016/6787854] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 10/24/2016] [Indexed: 01/28/2023] Open
Abstract
Changes in distribution policies have increased median MELD at transplant with recipients requiring increasing intensive care perioperatively. We aimed to evaluate association of preoperative variables with postoperative respiratory failure (PRF)/increased intensive care unit length of stay (ICU LOS)/short-term survival in a high MELD cohort undergoing liver transplant (LT). Retrospective analysis identified cases of PRF and increased ICU LOS with recipient, donor, and surgical variables examined. Variables were entered into regression with end points of PRF and ICU LOS > 3 days. 164 recipients were examined: 41 (25.0%) experienced PRF and 74 (45.1%) prolonged ICU LOS. Significant predictors of PRF with univariate analysis: BMI > 30, pretransplant MELD, preoperative respiratory failure, LVEF < 50%, FVC < 80%, intraoperative transfusion > 6 units, warm ischemic time > 4 minutes, and cold ischemic time > 240 minutes. On multivariate analysis, only pretransplant MELD predicted PRF (OR 1.14, p = 0.01). Significant predictors of prolonged ICU LOS with univariate analysis are as follows: pretransplant MELD, FVC < 80%, FEV1 < 80%, deceased donor, and cold ischemic time > 240 minutes. On multivariate analysis, only pretransplant MELD predicted prolonged ICU LOS (OR 1.28, p < 0.001). One-year survival among cohorts with PRF and increased ICU LOS was similar to subjects without. Pretransplant MELD is a robust predictor of PRF and ICU LOS. Higher MELDs at LT are expected to increase need for ICU utilization and modify expectations for recovery in the immediate postoperative period.
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Sotiropoulos GC, Vernadakis S, Paul A, Hoyer DP, Saner FH, Gallinat A. Single-Center Experience on Liver Transplantation for Model for End-Stage Liver Disease Score 40 Patients. Dig Dis Sci 2016; 61:3346-3353. [PMID: 27538409 DOI: 10.1007/s10620-016-4274-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 08/08/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Organ shortage and waiting list mortality have led to changes in the allocation policy in Eurotransplant. AIM To identify factors influencing the survival of liver transplanted patients with model for end-stage liver disease (MELD) score of 40. PATIENTS AND METHODS Data of listed adult patients who reached a MELD score 40 in the period 12/2006-06/2010 were reviewed. Donor/graft and recipient characteristics, and operative details were analyzed. Statistical analysis encompassed Kaplan-Meier analysis/log-rank test as well as univariate and multivariable regression analyses. RESULTS Forty-eight patients achieved a MELD score 40. Thirty patients were transplanted, whereas 18 patients were not. Three-month, 1-year, and 5-year patient and graft survival for transplanted patients was 53, 50, and 47 %, respectively. Three-month and 1-year survival after listing was 11 and 6 % for not transplanted patients, respectively (p < 0.0001). Multivariable analysis revealed pre-operative dialysis (p = 0.0246) and portal vein thrombosis (PVT) (p = 0.0231) to be independent prognostic factors for post-transplant patient survival. A point scoring system was created, which reached statistical significance (p = 0.0007). One-year and 5-year survival for scores 0, 1, and 2 were 72 and 64, 42 and 42 and 0 %, respectively. There was no statistical difference in transplantation costs between patients who survived or died (p = 0.1578). CONCLUSIONS At our center, coexistence of pre-operative dialysis and PVT represents a clear contraindication for LT regarding MELD score 40 patients.
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Affiliation(s)
- Georgios C Sotiropoulos
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany.
| | - Spyridon Vernadakis
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Dieter P Hoyer
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Fuat H Saner
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Anja Gallinat
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
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33
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End-stage liver disease patients with MELD >40 have higher waitlist mortality compared to Status 1A patients. Hepatol Int 2016; 10:838-46. [DOI: 10.1007/s12072-016-9735-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 04/20/2016] [Indexed: 12/14/2022]
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34
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Bittermann T, Goldberg DS. Reply to "Is the post-transplant survival the unique Holy Grail?". J Hepatol 2016; 64:523-524. [PMID: 26592353 DOI: 10.1016/j.jhep.2015.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 11/06/2015] [Indexed: 12/04/2022]
Affiliation(s)
- Therese Bittermann
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, United States
| | - David S Goldberg
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, United States; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, United States.
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Galbois A, Maury E, Carbonell N, Guidet B. Is the post-transplant survival the unique Holy Grail? J Hepatol 2016; 64:522-523. [PMID: 26596410 DOI: 10.1016/j.jhep.2015.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 10/18/2015] [Accepted: 10/20/2015] [Indexed: 12/04/2022]
Affiliation(s)
- Arnaud Galbois
- AP-HP, CHU Saint-Antoine, Service de Réanimation Médicale, 75012 Paris, France; Générale de Santé, Hôpital Privé Claude Galien, Service de Réanimation Polyvalente, 91480 Quincy-sous-Sénart, France.
| | - Eric Maury
- AP-HP, CHU Saint-Antoine, Service de Réanimation Médicale, 75012 Paris, France; Université Pierre et Marie Curie (UPMC), Univ Paris 06, Sorbonne Universités, Paris, France
| | - Nicolas Carbonell
- AP-HP, CHU Saint-Antoine, Service d'Hépatologie, 75012 Paris, France
| | - Bertrand Guidet
- AP-HP, CHU Saint-Antoine, Service de Réanimation Médicale, 75012 Paris, France; Université Pierre et Marie Curie (UPMC), Univ Paris 06, Sorbonne Universités, Paris, France
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