Impact of pretransplant MELD score on posttransplant outcome in living donor liver transplantation

The Predictive Role of Model for End-Stage Liver Disease-Lactate and Lactate Clearance for In-Hospital Mortality Among a National Cirrhosis Cohort

The burden of cirrhosis hospitalizations is increasing. The admission Model for End-Stage Liver Disease-lactate (MELD-lactate) was recently demonstrated to be a superior predictor of in-hospital mortality compared with MELD in limited cohorts. We identified specific classes of hospitalizations where MELD-lactate may be especially useful and evaluated the predictive role of lactate clearance. This was a retrospective cohort study of 1036 cirrhosis hospitalizations for gastrointestinal bleeding, infection, or other portal hypertension-related indications in the Veterans Health Administration where MELD-lactate was measured on admission. Performance characteristics for in-hospital mortality were compared between MELD-lactate and MELD/MELD-sodium (MELD-Na), with stratified analyses of MELD categories (≤15, >15 to <25, ≥25) and reason for admission. We also incorporated day 3 lactate levels into modeling and tested for an interaction between day 1 MELD-lactate and day 3 lactate clearance. MELD-lactate had superior discrimination for in-hospital mortality compared with MELD or MELD-Na (area under the curve [AUC] 0.789 versus 0.776 versus 0.760, respectively; P < 0.001) and superior calibration. MELD-lactate had higher discrimination among hospitalizations with MELD ≤15 (AUC 0.763 versus 0.608 for MELD, global P = 0.01) and hospitalizations for infection (AUC 0.791 versus 0.674 for MELD, global P < 0.001). We found a significant interaction between day 1 MELD-lactate and day 3 lactate clearance; heat maps were created as clinical tools to risk-stratify patients based on these clinical data. MELD-lactate had significantly superior performance in predicting in-hospital mortality among patients hospitalized for infection and/or with MELD ≤15 when compared with MELD or MELD-Na. Incorporating day 3 lactate clearance may further improve prognostication.

Delta MELD as a predictor of early outcome in adult-to-adult living donor liver transplantation

BACKGROUND/AIMS

An increased post-operative mortality risk has been reported among patients who undergo living donor liver transplantation (LDLT) with higher model for end-stage liver disease (MELD) scores. In this study, we investigated the effect of MELD score reduction on post-operative outcomes in patients with a high MELD (≥20) score by pre-transplant management.

MATERIALS AND METHODS

We retrospectively analyzed 386 LDLT cases, and patients were divided into low-MELD (<20, n=293) vs. high-MELD (≥20, n=93) groups according to their MELD score at the time of index hospitalization. Patients in the high-MELD group were managed specifically according to a treatment algorithm in an effort to decrease the MELD score. Patients in the high-MELD group were further divided into 2 subgroups: (1) responders (n=34) to pre-transplant treatment with subsequent reduction of the MELD score by a minimum of 1 point vs. (2) non-responders (n=59), whose MELD score remained unchanged or further increased on the day of LDLT. Responders vs. non-responders were compared according to etiology, demographics, and survival.

Adult Living Donor Liver Transplantation for Acute-on-Chronic Liver Failure in High-Model for End-Stage Liver Disease Score Patients

The large volume of adult living donor liver transplantations (ALDLTs) at our center affords a unique opportunity to examine the impact of acute-on-chronic liver failure (ACLF) among high-Model for End-Stage Liver Disease MELD score patients. From February 1998 to March 2010, 1958 cirrhotic recipients were analyzed to study the relationship between MELD scores and ALDLT outcomes. A total of 327 high-MELD score recipients were categorized into ACLF and non-ACLF groups, and their outcomes were compared. The 5-year graft and patient survival in the high-MELD group were 75.2% and 76.4%, respectively, which were significantly worse than the low and intermediate MELD groups. The presence of ACLF associated with higher MELD scores appeared to be the dominant factor responsible for the inferior results of patients with MELD score of 30-34 points. The 5-year graft survivals in the ACLF group was 70.5% and in the non-ACLF group it was 81.0% (p = 0.035). Therefore, ALDLT should be performed as soon as possible in high-MELD score patients prior to ACLF development. Moreover, ACLF patients should be separately categorized when analyzing the outcomes of ALDLT. ALDLT for ACLF patients should not be discouraged because favorable outcomes can be expected through timely ALDLT and comprehensive management.

Proteinuria can predict prognosis after liver transplantation

Background

Proteinuria is a manifestation of renal dysfunction and it has been demonstrated to be a significant prognostic factor in various clinical situations. The study was designed to analyze prognosis of patients receiving liver transplantation as well as to determine predictive performance of perioperative proteinuria.

Methods

We retrospectively reviewed data of patients who had received a liver transplant in a medical center between 2002 and 2010. Demographic information and clinical characteristic parameters were recorded on the day of intensive care unit admission before operation and on postoperative days 1, 7, and 14.

Results

Among a total of 323 patients, in-hospital mortality and 90-day mortality rates were 13.0 % (42/323) and 14.2 % (46/323), respectively. Patients with proteinuria on admission had higher rates of acute kidney injury (26.8 % vs. 8.8 %, p < 0.001), severe infection episodes (48.8 % vs. 30.7 %, p = 0.023), hospital death (31.1 % vs. 10.1 %, p < 0.001), and 90-day mortality (37.7 % vs. 10.9 %, p < 0.001). Multivariate analysis showed that proteinuria on admission and Sequential Organ Failure Assessment (SOFA) score were independent predictors of in-hospital mortality. The discriminatory ability of proteinuria plus SOFA was even better than that of SOFA alone, especially on postoperative day 1.

Conclusions

The presence of proteinuria before liver transplantation is supposed to be recognized as a negative predictor for in-hospital survival. Moreover, the presence of proteinuria after liver transplantation can assist in the early prediction of poor short-term prognosis for patients receiving liver transplantation.

Recipient Age and Mortality Risk after Liver Transplantation: A Population-Based Cohort Study

The aim of the present large population-based cohort study is to explore the risk factors of age-related mortality in liver transplant recipients in Taiwan. Basic information and data on medical comorbidities for 2938 patients who received liver transplants between July 1, 1998, and December 31, 2012, were extracted from the National Health Insurance Research Database on the basis of ICD-9-codes. Mortality risks were analyzed after adjusting for preoperative comorbidities and compared among age cohorts. All patients were followed up until the study endpoint or death. This study finally included 2588 adults and 350 children [2068 (70.4%) male and 870 (29.6%) female patients]. The median age at transplantation was 52 (interquartile range, 43–58) years. Recipients were categorized into the following age cohorts: <20 (n = 350, 11.9%), 20–39 (n = 254, 8.6%), 40–59 (n = 1860, 63.3%), and ≥60 (n = 474, 16.1%) years. In the total population, 428 deaths occurred after liver transplantation, and the median follow-up period was 2.85 years (interquartile range, 1.2–5.5 years). Dialysis patients showed the highest risk of mortality irrespective of age. Further, the risk of death increased with an increase in the age at transplantation. Older liver transplant recipients (≥60 years), especially dialysis patients, have a higher mortality rate, possibly because they have more medical comorbidities. Our findings should make clinicians aware of the need for better risk stratification among elderly liver transplantation candidates.

Incidence and Outcomes of Acute Renal Failure Following Liver Transplantation: A Population-Based Cohort Study

The aim of our large, population-based, cohort study was to explore the risk factors of acute renal failure (ARF) after liver transplant (LT) in Taiwan.From the Taiwanese National Health Insurance Research Database, 2862 patients who had undergone LT without pretransplant dialysis between July 1, 1998, and December 31, 2012, were identified. Preoperative, operative, and perioperative risks factors were considered and analyzed using logistic regression analysis, after adjusting for age and sex. All patients were followed up until the study endpoint or death.The final dataset included 214 patients with ARF and 2648 without ARF post-LT. Preoperative cerebrovascular diseases were the most important identifiable risk factor for ARF post-LT. Comparison of outcomes for patients "with" and "without" ARF indicated higher incidence rates of bacteremia, pneumonia, and postoperative bleeding, as well as longer stays in both intensive care unit and hospital. Kaplan-Meier mortality curves identified higher rates of mortality for patients' developing ARF at 1-year post-LT and overall at 14.5 years postsurgery.We provide evidence of a high incidence of ARF post-LT in Taiwan, with documented association of ARF with higher incidence rates of morbidity and mortality in this clinical population. The most important identifiable risk factor for ARF in our study was cerebrovascular diseases.

Scoring systems for predicting mortality after liver transplantation

Background

Liver transplantation can prolong survival in patients with end-stage liver disease. We have proposed that the Sequential Organ Failure Assessment (SOFA) score calculated on post-transplant day 7 has a great discriminative power for predicting 1-year mortality after liver transplantation. The Chronic Liver Failure - Sequential Organ Failure Assessment (CLIF-SOFA) score, a modified SOFA score, is a newly developed scoring system exclusively for patients with end-stage liver disease. This study was designed to compare the CLIF-SOFA score with other main scoring systems in outcome prediction for liver transplant patients.

Methods

We retrospectively reviewed medical records of 323 patients who had received liver transplants in a tertiary care university hospital from October 2002 to December 2010. Demographic parameters and clinical characteristic variables were recorded on the first day of admission before transplantation and on post-transplantation days 1, 3, 7, and 14.

Results

The overall 1-year survival rate was 78.3% (253/323). Liver diseases were mostly attributed to hepatitis B virus infection (34%). The CLIF-SOFA score had better discriminatory power than the Child-Pugh points, Model for End-Stage Liver Disease (MELD) score, RIFLE (risk of renal dysfunction, injury to the kidney, failure of the kidney, loss of kidney function, and end-stage kidney disease) criteria, and SOFA score. The AUROC curves were highest for CLIF-SOFA score on post-liver transplant day 7 for predicting 1-year mortality. The cumulative survival rates differed significantly for patients with a CLIF-SOFA score ≤8 and those with a CLIF-SOFA score >8 on post-liver transplant day 7.

Conclusion

The CLIF-SOFA score can increase the prediction accuracy of prognosis after transplantation. Moreover, the CLIF-SOFA score on post-transplantation day 7 had the best discriminative power for predicting 1-year mortality after liver transplantation.

Section 12. Living donor liver transplantation for patients with high model for end-stage liver disease scores and acute liver failure

Living donor liver transplantation (LDLT) for patients with high model for end-stage liver disease score and acute liver failure patients have little or not gained any substantial following among Western centers because of the "donor high risk-low recipient benefit scenario" that puts the donor at a significant risk against the survival odds for a recipient who is receiving a partial graft and considered marginal by Western standards. In most Asian countries, there is sometimes no other source of live graft but a willing live liver donor. There are individual Asian center reports that conclude that LDLT has comparable outcome to deceased donor liver transplant. However, the outcomes of a large number of patients after undergoing adult LDLT for high model for end-stage liver disease scores and acute liver failure at a single center have not been investigated. Here in, we present our experience with such subgroup of patients undergoing LDLT.

A high model for end-stage liver disease score should not be considered a contraindication to living donor liver transplantation

OBJECTIVE

To analyze the outcomes of patients with high Model for End-Stage Liver Disease (MELD) scores who underwent adult-to-adult live donor liver transplantation (A-A LDLT).

MATERIALS AND METHODS

From September 2002 to October 2010, a total of 152 adult patients underwent A-A LDLT in our institution. Recipients were stratified into a low MELD score group (Group L; MELD score≤30) and a high MELD score group (Group H; MELD score>30) to compare short-term and long-term outcomes.

RESULTS

Of the 152 adult patients who underwent A-A LDLT, 9 were excluded from the analysis because they received ABO-incompatible grafts. Group H comprised 23 and Group L 120 patients. The median follow-up was 21.5 months (range, 3 to 102 m). The mean MELD score was 15.6 in Group L and 36.7 in Group H. There were no significant differences in the mean length of stay in the intensive care unit (Group L: 3.01 days vs Group H: 3.09 days, P=.932) or mean length of hospital stay (Group L: 17.89 days vs. Group H: 19.91 days, P=0.409). There were no significant differences in 1-, 3-, or 5-year survivals between patients in Groups L versus H (91.5% vs 94.7%; 86.4% vs 94.7%; and 86.4% vs 94.7%; P=.3476, log rank).

CONCLUSION

The short-term and long-term outcomes of patients with high MELD scores who underwent A-A LDLT were similar to those of patients with low MELD scores. Therefore, we suggest that high MELD scores are not a contraindication to LDLT.

Scoring short-term mortality after liver transplantation

Liver transplantation can prolong survival and improve the quality of life of patients with end-stage liver disease. This study retrospectively reviewed the medical records of 149 patients who had received liver transplants in a tertiary care university hospital from January 2000 to December 2007. Demographic, clinical, and laboratory variables were recorded. Each patient was assessed by 4 scoring systems before transplantation and on postoperative days 1, 3, 7, and 14. The overall 1-year survival rate was 77.9%. The Sequential Organ Failure Assessment (SOFA) score had better discriminatory power than the Child-Pugh points, Model for End-Stage Liver Disease score, and RIFLE (risk of renal dysfunction, injury to the kidney, failure of the kidney, loss of kidney function, and end-stage kidney disease) criteria. Moreover, the SOFA score on day 7 post-liver transplant had the best Youden index and highest overall correctness of prediction for 3-month (0.86, 93%) and 1-year mortality (0.62, 81%). Cumulative survival rates at the 1-year follow-up after liver transplantation differed significantly (P < 0.001) between patients who had SOFA scores < or = 7 on post-liver transplant day 7 and those who had SOFA scores > 7 on post-liver transplant day 7. In conclusion, of the 4 evaluated scoring systems, only the SOFA scores calculated before liver transplantation were statistically significant predictors of 3-month and 1-year posttransplant mortality. SOFA on post-liver transplant day 7 had the best discriminative power for predicting 3-month and 1-year mortality after liver transplantation.

Live donor liver transplantation in high MELD score recipients

BACKGROUND

In 2002, the New York State Committee on Quality Improvement in Living Liver Donation prohibited live liver donation for potential recipients with Model for End-stage Liver Disease (MELD) scores greater than 25. Despite the paucity of evidence to support this recommendation, many centers in North America remain reluctant to offer living donor (LD) to patients with moderate to high MELD scores.

METHODS

We analyzed 271 consecutive adult-to-adult right lobe LD liver transplants performed at our institution between 2002 and 2008 to study the relationship, between recipient MELD scores and the outcome of LD liver transplantation. The recipients were categorized according to their MELD score into a low (Low: <25)and high (Hi: >or=25) MELD group. We compared short-term donor morbidity, graft loss within 30 days, length of hospital stay, biochemical markers of hepatocyte injury and graft function, and 90 day posttransplant complications including infection, rejection, bleeding, and renal failure. Long-term posttransplant outcome was measured by graft and patient survival after 1-, 3-, and 5-years.

RESULTS

Donor and recipient characteristics were similar between groups. Donor outcomes were similar in both groups. Peak recipient aspartat aminotransferase, alanine aminotransferase, and length of hospital stay were similar between both groups. The proportional decrease in postoperative INR and creatinine within the first week was greater in the high versus low MELD score group. High MELD score recipients had more frequent postoperative pneumonia (Low: 2.2% vs. Hi: 14%, P = 0.003), while no differences were observed in rates of biliary complications, rejection, renal failure, or overall infections. Recipients with a MELD <25 versus >or=25 had a similar 1-year (Low: 92% vs. Hi: 83%), 3-year (Low: 86% vs. Hi: 80%), and 5-year (Low: 78% vs. Hi: 80%) graft survival after LD liver transplantation (P = 0.51).

CONCLUSION

LD liver transplantation can provide excellent graft function and survival rates in high MELD score recipients. Thus, when deceased donor organs are scare, a high MELD score alone should not be an absolute contraindication to living liver donation.

Prediction of cardiac complications after liver transplantation

BACKGROUND

Orthotopic liver transplantation (OLT) stresses the cardiovascular system, and cardiac complications after OLT are common.

METHODS

Hundred ninety-seven patients (>or=40 years) who had OLT from 2002 to 2007 were reviewed to identify predictors of cardiac complications within 6 months after transplantation.

RESULTS

Median age was 56 years (40-75 years); 69% men. Reasons for OLT were hepatitis C virus (HCV) 45.5%, alcohol 22%, hepatocellular carcinoma (HCC) 8%, primary biliary cirrhosis 10%, and others 14.5%. Eighty-two patients suffered one or more cardiac complications within 6 months after OLT (pulmonary edema=61 [overt heart failure=7], arrhythmia=13, pulmonary hypertension=7, pericardial effusion=2, and right atrial thrombus=1). Cardiac causes were the leading cause of death (n=5; 23.8% of all mortality). By multivariate analysis, after adjusting for age and sex, independent predictors were adverse intraoperative cardiovascular events (adjusted odds ratio; 95% confidence interval: 5.89, 1.82-19.14), history of cardiac disease (2.42, 0.89-6.6), and i-MELD (integrated model for end-stage liver disease) score (1.08, 1.02-1.14), whereas adverse intraoperative cardiovascular events (5.73, 1.96-16.78) and i-MELD (1.07, 1.01-1.13) predicted pulmonary edema. None of the following variables predicted complications: age, sex, OLT indication, body mass index, blood pressure, alcohol and smoking history, pre-OLT investigations (chest X-ray, electrocardiogram, echocardiography, coronary angiography, pulmonary arterial pressure, and 2-methoxy isobutyl isonitrile scan), immunosuppressive treatment, or intraoperative variables (transfusion amount, cadaveric vs. living graft or cold ischemia and rewarming times).

CONCLUSIONS

Cardiac complications after OLT are common and were the leading cause of death after surgery. Adverse intraoperative cardiovascular events, previous cardiac disease, and advanced liver disease as quantified by i-MELD score predicted postoperative cardiac complications.

Should liver transplantation in patients with model for end-stage liver disease scores <or= 14 be avoided? A decision analysis approach

Studies have shown that liver transplantation offers no survival benefits to patients with Model for End-Stage Liver Disease (MELD) scores <or= 14 in comparison with remaining on the waitlist. The consensus of a 2003 transplant community national conference was that a minimum MELD score should be required for placement on the liver waitlist, but no minimum listing national policy was enacted at that time. We developed a Markov microsimulation model to compare results under the present US liver allocation policy with outcomes under a "Rule 14" policy of barring patients with a MELD score of <or=14 from the waitlist or transplantation. For probabilities in the microsimulation model, we used data on all adult patients (>or=18 years) listed for or undergoing primary liver transplantation in the United States for chronic liver disease from 1/1/2003 through 12/31/2007 with follow-up until 2/1/2008. The "Rule 14" policy gave a 3% improvement in overall patient survival over the present system at 1, 2, 3, and 4 years and predicted a 13% decrease in overall waitlist time for patients with MELD scores of 15 to 40. Patients with the greatest benefit from a "Rule 14" policy were those with MELD scores of 6 to 10, for whom a 17% survival advantage was predicted from waiting on the list versus undergoing transplantation. Our analysis supports changing the national liver allocation policy to not allow liver transplantation for patients with MELD <or= 14.

The model for end-stage liver disease (MELD)

The Model for End-stage Liver Disease (MELD) was initially created to predict survival in patients with complications of portal hypertension undergoing elective placement of transjugular intrahepatic portosystemic shunts. The MELD which uses only objective variables was validated subsequently as an accurate predictor of survival among different populations of patients with advanced liver disease. The major use of the MELD score has been in allocation of organs for liver transplantation. However, the MELD score has also been shown to predict survival in patients with cirrhosis who have infections, variceal bleeding, as well as in patients with fulminant hepatic failure and alcoholic hepatitis. MELD may be used in selection of patients for surgery other than liver transplantation and in determining optimal treatment for patients with hepatocellular carcinoma who are not candidates for liver transplantation. Despite the many advantages of the MELD score, there are approximately 15%-20% of patients whose survival cannot be accurately predicted by the MELD score. It is possible that the addition of variables that are better determinants of liver and renal function may improve the predictive accuracy of the model. Efforts at further refinement and validation of the MELD score will continue.

Elective Transjugular Intrahepatic Portosystemic Shunt Creation for Portal Decompression in the Immediate Pretransplantation Period in Adult Living Related Liver Transplant Recipient Candidates: Preliminary Results

PURPOSE

To evaluate (i) the efficacy of purposeful creation of transjugular intrahepatic portosystemic shunts (TIPS) before transplantation to optimize potential living related liver transplantation (LRLTx) and (ii) the efficacy of TIPS creation in this setting in reducing perioperative resource utilization.

MATERIALS AND METHODS

Retrospective review was performed of the records of patients who underwent adult LRLTx with or without preoperative TIPS creation from October 2003 through April 2005. Patients were evaluated for preoperative parameters (Child-Pugh class, Model for End-stage Liver Disease score, Acute Physiology and Chronic Health Evaluation [APACHE] II score, and coagulation parameters), intraoperative parameters (blood transfusion requirements and operative time), and postoperative parameters (intensive care unit stay, hospital stay, and 30-day repeat operation and mortality rates). Comparison between the two treatment groups was made with the Mann-Whitney U test. Within the TIPS group, comparison of blood transfusion requirements was performed by one-way analysis of variance based on the degree of portosystemic gradient reduction after TIPS creation.

RESULTS

Sixteen patients were included in the TIPS group, and 12 patients were included in the group without TIPS. Median time between TIPS and transplantation was 2 days. There was no statistical difference in the preoperative, intraoperative, and postoperative parameters between groups except for the APACHE II score (P<.002), which was higher in the TIPS group. Despite this, the outcome and postoperative hospital resource utilization were similar between groups. Intraoperative blood transfusion based on the degree of portosystemic gradient reduction after TIPS creation was not significantly different between groups.

CONCLUSIONS

Newly created TIPS do not interfere with the intraoperative technical and perioperative clinical aspects of adult LRLTx. Preoperative TIPS creation before transplantation may reduce the postoperative morbidity and mortality seen in liver transplant recipients who have a greater APACHE II score at the outset of treatment.

Improved survival after live donor adult liver transplantation (LDALT) using right lobe grafts: program experience and lessons learned

We present our program experience with 85 live donor adult liver transplantation (LDALT) procedures using right lobe grafts with five simultaneous live donor kidney transplants using different donors performed over a 6-year period. After an "early" 2-year experience of 25 LDALT procedures, program improvements in donor and recipient selection, preoperative imaging, donor and recipient surgical technique and immunosuppressive management significantly reduced operative mortality (16% vs. 3.3%, p = 0.038) and improved patient and graft 1-year survival in recipients during our "later" experience with the next 60 cases (January 2001 and March 2005; patient survival: early 70.8% vs. later 92.7%, p = 0.028; graft survival: Early 64% vs. later 91.1%, p = 0.019, respectively). Overall patient and graft survival were 82% and 80%. There was a trend for less postoperative complications (major and minor) with program experience (early 88% vs. later 66.7%; p = 0.054) but overall morbidity remained at 73.8%. Biliary complications (cholangitis, disruption, leak or stricture) were not influenced by program experience (early 32% vs. later 38%). Liver volume adjusted to 100% of standard liver volume (SLV) within 1 month post-transplant. Despite a high rate of morbidity after LDALT, excellent patient and graft survival can be achieved with program experience.

The survival benefit of liver transplantation

Demand for liver transplantation continues to exceed donor organ supply. Comparing recipient survival to that of comparable candidates without a transplant can improve understanding of transplant survival benefit. Waiting list and post-transplant mortality was studied among a cohort of 12 996 adult patients placed on the waiting list between 2001 and 2003. Time-dependent Cox regression models were fitted to determine relative mortality rates for candidates and recipients. Overall, deceased donor transplant recipients had a 79% lower mortality risk than candidates (HR = 0.21; p < 0.001). At Model for End-stage Liver Disease (MELD) 18-20, mortality risk was 38% lower (p < 0.01) among recipients compared to candidates. Survival benefit increased with increasing MELD score; at the maximum score of 40, recipient mortality risk was 96% lower than that for candidates (p < 0.001). In contrast, at lower MELD scores, recipient mortality risk during the first post-transplant year was much higher than for candidates (HR = 3.64 at MELD 6-11, HR = 2.35 at MELD 12-14; both p < 0.001). Liver transplant survival benefit at 1 year is concentrated among patients at higher risk of pre-transplant death. Futile transplants among severely ill patients are not identified under current practice. With 1 year post-transplant follow-up, patients at lower risk of pre-transplant death do not have a demonstrable survival benefit from liver transplant.