Pretransplant model for end-stage liver disease score as a predictor of postoperative complications after liver transplantation. Transplant Proc. 2009;41:1240-1242. [PMID: 19460528 DOI: 10.1016/j.transproceed.2009.02.046]

Outcome of liver cirrhosis patients requiring prolonged mechanical ventilation

Acute respiratory failure requiring mechanical ventilation is a major indicator of intensive care unit (ICU) admissions in cirrhotic patients and is an independent risk factor for ICU mortality. This retrospective study aimed to investigate the outcome and mortality risk factors in patients with liver cirrhosis (LC) who required prolonged mechanical ventilation (PMV) between 2006 and 2013 from two databases: Taiwan’s National Health Insurance Research Database (NHIRD) and a hospital database. The hospital database yielded 58 LC patients (mean age: 65.3 years; men: 65.5%). The in-hospital mortality was significantly higher than in patients without LC. Based on the NHIRD database of PMV cases, patients were age-gender matched in a ratio of 1:2 for patients with and without LC. Model for End-Stage Liver Disease (MELD) score was calculated. The mortality was higher in patients with LC (19.5%) than those without LC (18.12%), though not statistically significant (p = 0.0622). Based on the hospital database, risk factor analysis revealed that patients who died had significant higher MELD score than the survivors (18.9 vs 13.7, p = 0.036) and patients with MELD score of >23 had higher risk of mortality than patients with MELD score of ≤23 (adjusted OR:9.26, 95% CI: 1.96–43.8). In conclusion, the in-hospital mortality of patients with high MELD scores who required PMV was high. MELD scores may be useful predictors of mortality in these patients.

Transesophageal ultrasonography during orthotopic liver transplantation: Show me more

The first perioperative transesophageal echocardiography (TEE) guidelines published 21 years ago were mainly addressed to cardiac anesthesiologists. TEE has since expanded its role outside this setting and currently represents an invaluable tool to assess chamber sizes, ventricular hypertrophy, and systolic, diastolic, and valvular function in patients undergoing orthotopic liver transplantation (OLT). Right-sided microemboli, right ventricular dysfunction, and patent foramen ovale (PFO) are the most common intra-operative findings described during OLT. However, left ventricular outflow tract obstruction and left ventricular ballooning syndrome are more difficult to recognize and less frequent. Transesophageal ultrasonography (TEU) during OLT is also underused. Its applications are as follows: (1) assistance in the difficult placement of pulmonary arterial catheters; (2) help with catheterization of great vessels for external veno-venous bypass placement; (3) intra-operative evaluation of surgical liver anastomosis patency, if feasible, through the liver window; and (4) intra-operative investigation of "acute hypoxemia" due to pulmonary and cardiac issues using trans-esophageal lung ultrasound (TELU). The aims of this review are as follows: (1) to summarize the uses of TEE and TEU throughout all phases of OLT, and (2) to describe other new feasible applications.

Cardiac output measurement in liver transplantation patients using pulmonary and transpulmonary thermodilution: a comparative study

During liver transplantation surgery, the pulmonary artery catheter-despite its invasiveness-remains the gold standard for measuring cardiac output. However, the new EV1000 transpulmonary thermodilution calibration technique was recently introduced into the market by Edwards LifeSciences. We designed a single-center prospective observational study to determine if these two techniques for measuring cardiac output are interchangeable in this group of patients. Patients were monitored with both pulmonary artery catheter and the EV1000 system. Simultaneous intermittent cardiac output measurements were collected at predefined steps: after induction of anesthesia (T1), during the anhepatic phase (T2), after liver reperfusion (T3), and at the end of the surgery (T4). The 4-quadrant and polar plot techniques were used to assess trending ability between the two methods. We enrolled 49 patients who underwent orthotopic liver transplantation surgery. We analyzed a total of 588 paired measurements. The mean bias between pulmonary artery catheter and the EV1000 system was 0.35 L/min with 95% limits of agreement of - 2.30 to 3.01 L/min, and an overall percentage error of 35%. The concordance rate between the two techniques in 4-quadrant plot analysis was 65% overall. The concordance rate of the polar plot showed an overall value of 83% for all pairs. In the present study, in liver transplantation patients we found that intermittent cardiac output monitoring with EV1000 system showed a percentage error compared with pulmonary artery catheter in the acceptable threshold of 45%. On the others hand, our results showed a questionable trending ability between the two techniques.

Ventilator associated pneumonia following liver transplantation: Etiology, risk factors and outcome

AIM: To determine the incidence, etiology, risk factors and outcome of ventilator-associated pneumonia (VAP) in patients undergoing orthotopic liver transplantation (OLT).

METHODS: This retrospective study considered 242 patients undergoing deceased donor OLT. VAP was diagnosed according to clinical and microbiological criteria.

RESULTS: VAP occurred in 18 (7.4%) patients, with an incidence of 10 per 1000 d of mechanical ventilation (MV). Isolated bacterial etiologic agents were mainly Enterobacteriaceae (79%). Univariate logistic analysis showed that model for end-stage liver disease (MELD) score, pre-operative hospitalization, treatment with terlipressin, Child-Turcotte-Pugh score, days of MV and red cell transfusion were risk factors for VAP. Multivariate analysis, considering significant risk factors in univariate analysis, demonstrated that pneumonia was strongly associated with terlipressin usage, pre-operative hospitalization, days of MV and red cell transfusion. Mortality rate was 22% in the VAP group vs 4% in the group without VAP.

CONCLUSION: Our data suggest that VAP is an important cause of nosocomial infection during postoperative period in OLT patients. MELD score was a significant risk factor in univariate analysis. Multiple transfusions, treatment with terlipressin, preoperative hospitalization rather than called to the hospital while at home and days of MV constitute important risk factors for VAP development.

Comparison of Different Scoring Systems Based on Both Donor and Recipient Characteristics for Predicting Outcome after Living Donor Liver Transplantation

BACKGROUND AND OBJECTIVES

In order to provide a good match between donor and recipient in liver transplantation, four scoring systems [the product of donor age and Model for End-stage Liver Disease score (D-MELD), the score to predict survival outcomes following liver transplantation (SOFT), the balance of risk score (BAR), and the transplant risk index (TRI)] based on both donor and recipient parameters were designed. This study was conducted to evaluate the performance of the four scores in living donor liver transplantation (LDLT) and compare them with the MELD score.

PATIENTS AND METHODS

The clinical data of 249 adult patients undergoing LDLT in our center were retrospectively evaluated. The area under the receiver operating characteristic curves (AUCs) of each score were calculated and compared at 1-, 3-, 6-month and 1-year after LDLT.

RESULTS

The BAR at 1-, 3-, 6-month and 1-year after LDLT and the D-MELD and TRI at 1-, 3- and 6-month after LDLT showed acceptable performances in the prediction of survival (AUC>0.6), while the SOFT showed poor discrimination at 6-month after LDLT (AUC = 0.569). In addition, the D-MELD and BAR displayed positive correlations with the length of ICU stay (D-MELD, p = 0.025; BAR, p = 0.022). The SOFT was correlated with the time of mechanical ventilation (p = 0.022).

CONCLUSION

The D-MELD, BAR and TRI provided acceptable performance in predicting survival after LDLT. However, even though these scoring systems were based on both donor and recipient parameters, only the BAR provided better performance than the MELD in predicting 1-year survival after LDLT.

MELD-based graft allocation system fails to improve liver transplantation efficacy in a single-center intent-to-treat analysis

BACKGROUND

Since March 2007, priority access to liver transplantation in France has been given to patients with the highest MELD scores.

OBJECTIVE

To undertake an intent-to-treat comparison of center-based vs. MELD-based liver graft allocation.

METHODS

Retrospective cohort analysis (patients listed 6th March 2007 to 5th March 2009; MELD period) with a matched historical cohort (patients listed 6th March 2005 to 5th March 2007; pre-MELD period) in a single high-volume center. Analysis was on an intent-to-treat basis, i.e. starting on the day of wait listing.

RESULTS

Compared to pre-MELD, fewer patients with a MELD score less or equal to 14 (P=0.002), and more patients with a MELD greater or equal to 24 (P<0.05) were transplanted during the MELD period. For HCC candidates, median waiting time increased (121 vs. 54 days, P=0.01), transplantation rate halved (35% vs. 73.5%, P<0.001) and dropouts due to tumor progression increased (16% vs. 0%, P<0.001). Moreover, postoperative course did not change significantly except for infectious complications (35% vs. 24%, P=0.02); overall patient survival was 69.8 ± 3.1% vs. 76 ± 2.9% (P=0.29) and overall graft survival was 77.6 ± 3.4% vs. 82.8 ± 2.9% (P=0.29). Transplant failures were mainly due to deaths on the waiting list in the previous system, but to dropouts related to disease progression in the new system. Cirrhotic patient survival rate did not change (78.1 ± 4.4% vs. 73.5 ± 4.5%, P=0.42), while that of HCC patients decreased (65.3 ± 5.3% vs. 86.8 ± 4.4%, P=0.01). Post-transplant survival worsened significantly according to pre-transplant MELD score (P=0.009).

CONCLUSION

The MELD-based graft allocation system introduced discrimination against HCC patients, whose incidence has increased dramatically, and should be reevaluated.

Relationship between postoperative lung atelectasis and position of the endotracheal tube in pediatric living-donor liver transplantation

OBJECTIVE

The aims of current study were: 1) to evaluate the incidence of lung atelectasis; and 2) to investigate whether or not the position of the endotracheal (ET) tube is associated with this complication.

METHODS

The medical records and chest roentgenograms of 183 pediatric patients who underwent living-donor liver transplantation were retrospectively reviewed and analyzed. Patients without atelectasis were grouped in group I (GI) and those with atelectasis in group II (GII). The patients' characteristics and ET tube level between groups were compared with unpaired Student's t test. Multiple binary logistic regressions were also performed to identify the important risk factors associated with lung atelectasis.

RESULTS

Right upper lung (RUL) atelectsis could be found in ET tube at any level from T1 to T5, with incidence rates of 12.7%, 15.2%, 26.3%, 6.7%, and 100% for T1, T2, T3, T4, and T5, respectively. The incidence of atelectasis is 16.6%, and all of the atelectasis occurred in the RUL. No significant difference between groups was observed in the patients' characteristics, except for the amount of preoperative ascites. The likelihood of this risk factor could not be confirmed by multivariate binary logistic regression analysis.

CONCLUSIONS

The incidence of lung atelectasis in our study was 16.6%, which all occurred in the RUL. No predictive risk factor from the patients' characteristics could be found, and no correlation between the level of the ET tube and the occurrence of RUL atelectasis could be observed.

The use of perioperative serial blood lactate levels, the APACHE II and the postoperative MELD as predictors of early mortality after liver transplantation

PURPOSE: To evaluate the accuracy of different parameters in predicting early (one-month) mortality of patients submitted to orthotopic liver transplantation (OLT). METHODS: This is a retrospective study of forty-four patients (38 males and 10 females, mean age of 52.2 ± 8.9 years) admitted to the Intensive Care Unit of a tertiary hospital. Serial lactate blood levels, APACHE II, MELD post-OLT, creatinine, bilirubin and INR parameters were analyzed by receiver-operator characteristic (ROC) curves as evidenced by the area under the curve (AUC). The level of significance was set at 0.05. RESULTS: The mortality of OLT patients within one month was 17.3%. Differences in blood lactate levels became statistically significant between survivors and nonsurvivors at the end of the surgery (p<0.05). The AUC was 0.726 (95%CI = 0.593-0.835) for APACHE II (p = 0.02); 0.770 (95%CI = 0.596-0.849) for blood lactate levels (L7-L8) (p = 0.03); 0.814 (95%CI = 0.690-0.904) for MELD post-OLT (p < 0.01); 0.550 (95%CI = 0.414-0.651) for creatinine (p = 0.64); 0.705 (95%CI = 0.571-0.818) for bilirubin (p = 0.05) and 0.774 (95%CI = 0.654-0.873) for INR (p = 0.02). CONCLUSION: Among the studied parameters, MELD post-OLT was more effective in predicting early mortality after OLT.

Comparison of acute physiology and chronic health evaluation II death risk, Child-Pugh, Charlson, and model for end-stage liver disease indexes to predict early mortality after liver transplantation

OBJECTIVE

This study sought to determine which prognostic index was the most efficient to predict early (1-month) mortality of patients undergoing orthotopic liver transplantation (OLT).

MATERIALS AND METHODS

This retrospective study included 63 patients including 49 males and 14 females of overall median age 51.6 ± 9.7 years who were admitted to the intensive care unit (ICU) of a tertiary hospital. The Acute Physiology and Chronic Health Evaluation II (APACHE II) death risk, Child-Pugh, Charlson, and Model for End-stage Liver Disease (MELD) indices pre-OLT and post-OLT were analyzed by generation of receiver operating characteristic (ROC) curves to determine the area under the ROC curve (AUC), as a predictive factor for each index. The level of significance was set at P < .05.

RESULTS

The general 1-month posttransplantation mortality rate of OLT patients was 19% (n = 12 p). The AUC was 0.81 (confidence interval [CI] = 0.66-0.96; sensitivity = 72.5; specificity = 83.3) for APACHE II death risk; 0.74 (CI = 0.57-0.92; sensitivity = 76.5; specificity = 66.7) for MELD post-OLT; 0.70 (CI = 0.54-0.85; sensitivity = 64.7; specificity = 66.7) for Child-Pugh; 0.57 (CI = 0.36-0.78; sensitivity = 74.5; specificity = 50.0) for Charlson; and 0.50 (CI = 0.32-0.69; sensitivity = 98.0; specificity = 16.7) for MELD Pre-OLT.

CONCLUSION

Among the studied indices, the APACHE II death risk scoring system was the most effective to predict early mortality after OLT.

The model for end-stage liver disease allocation system for liver transplantation saves lives, but increases morbidity and cost: a prospective outcome analysis

We analyzed the first 100 patients who underwent liver transplantation by Model for End-Stage Liver Disease (MELD) allocation, and compared the outcome of patients on the waiting list and after orthotopic liver transplantation with the last 100 patients who underwent transplantation prior to the introduction of the MELD system in July 2007. MELD allocation resulted in decreased waiting list mortality (386 versus 242 deaths per 1000 patient-years, P < 0.0001) and the transplantation of sicker recipients (uncorrected median MELD score 13.5 versus 20, P = 0.003). Recipient posttransplant morbidity was significantly higher, mainly caused by increased percentage of renal failure requiring renal replacement therapy (13 versus 46%, P < 0.0001). However, kidney function recovered in most cases within 6 months after OLT. Hospital mortality remained similar in both groups (6% versus 9%). Patient 1-year survival was 91% versus 83% (pre-MELD versus MELD era, P = 0.2154), graft 1-year survival was 88% versus 78% (P = 0.1013), respectively. Costs accumulated were significantly higher after introduction of the MELD policy (US $81,967 versus US $127,453, a 55% increase, P = 0.02) with a strong correlation with the individual MELD score (P < 0.0001). The MELD system addresses the goal of fairness well. However, the postoperative course appears more difficult in the MELD era with increased financial burden, but reasonable patient and graft survival. This is the inevitable price to balance justice and utility in liver graft allocation.

Perioperative risk factors for pulmonary complications after liver transplantation

Using monofactorial and multivariate logistic regression analyses, the correlation of perioperative risk factors with postoperative pulmonary complications (PPCs) within 1 month after orthotopic liver transplantation (OLT) was investigated. Data on 107 patients (median age 46.8 years, 72% male) with end-stage liver disease who received OLT were retrospectively analysed. The incidence of PPCs was 60.7%. Overall mortality was 13.1% and pulmonary causes accounted for 85.7% of deaths. Mortality was 18.5% and 4.8% for patients with and without pulmonary complications, respectively. Independent risk factors for PPCs were a preoperative model for end-stage liver disease (MELD) score > or =25, intraoperative fluid transfusion volume > 10 1 and intraoperative blood transfusion volume > 4 l. A fluid balance of < or = -300 ml for > or =2 days of the first 3 days after surgery was protective. Other variables studied did not predict PPCs. It was concluded that improving the patient's preoperative medical condition, restricting intraoperative transfusion volumes and maintaining a negative fluid balance in the first 3 days after operation may decrease PPCs.

Outcome of liver transplantation based on donor graft quality and recipient status

BACKGROUND

Availability of suitable donor organs has always limited the number of liver transplantations performed. Use of marginal donor organs is an alternative to overcome organ shortage.

OBJECTIVE

To analyze the effect of various combinations of donor organ quality and recipient status on the outcome of liver transplantation.

MATERIALS AND METHODS

Data from 260 whole-liver transplantations performed between January 2003 and September 2009 were analyzed retrospectively. Study groups were established according to donor organ quality (marginal score 0-1 vs 2-5) and recipient status (Model for End-Stage Liver Disease [MELD] score <17 or >17). In patients at low risk, 102 received optimal grafts (good-to-good group [G/G], and 75 received marginal grafts (bad-to-good group [B/G]. In patients at high risk, 46 received optimal grafts (good-to-bad group [G/B], and 37 received marginal grafts (bad-to-bad group [B/B].

RESULTS

No differences were observed in cumulative patient and graft survival rates; however, total survival differed in the early period after transplantation, that is, within 1 year. There was a higher rate of overall postoperative complications including initial poor graft function, bleeding, infection, and kidney failure in group B/B compared with group G/B (25 of 37 patients [67.5%] vs 27 of 46 patients [59.0%]), group B/G (25 of 37 patients [68%] vs 39 of 75 patients [52%], and group G/G (25 of 37 patients [68%] vs 43 of 102 patients [42%]) (P = .04). Patients with a high MELD score (G/B and B/B) demonstrated increased risk of postoperative complications. Use of donor organs with marginal score of 2 or higher in patients with high MELD scores increased early patient mortality.

CONCLUSION

In summary, patients with a high MELD score (G/B and B/B) are at an increased risk of post-OLT complications. In contrast, use of marginal grafts (B/G and B/B) increased the rate of hepatitis C virus recurrence and decreased the response rate to antiviral therapy. The combination of impaired donor grafts and recipients at high risk should be avoided.

Multivessel coronary artery disease predicts mortality, length of stay, and pressor requirements after liver transplantation

The optimal preoperative cardiac evaluation strategy for patients with end-stage liver disease (ESLD) undergoing liver transplantation remains unknown. Patients are frequently referred for cardiac catheterization, but the effects of coronary artery disease (CAD) on posttransplant mortality are also unknown. We sought to determine the contribution of CAD and multivessel CAD in particular to posttransplant mortality. We performed a retrospective study of ESLD patients undergoing cardiac catheterization before liver transplant surgery between August 1, 2004 and August 1, 2007 to determine the effects of CAD on outcomes after transplantation. Among 83 patients who underwent left heart catheterization, 47 underwent liver transplantation during the follow-up period. Twenty-one of all ESLD patients who underwent liver transplantation (45%) had CAD. Fifteen of the transplant patients with CAD (71%) had multivessel disease. Among transplant patients, the presence of multivessel CAD (versus no CAD) was predictive of mortality (27% versus 4%, P = 0.046), increased length of stay (22 versus 15 days, P = 0.050), and postoperative pressor requirements (27% versus 4%, P = 0.029). Interestingly, neither the presence of any CAD nor the severity of stenosis in any single coronary artery predicted mortality. Furthermore, none of the traditional clinical predictors (age, gender, diabetes, creatinine, ejection fraction, and Model for End-Stage Liver Disease score) were predictive of mortality among transplant recipients. In conclusion, multivessel CAD is associated with higher mortality after liver transplantation when it is documented angiographically before transplantation, even in the absence of severe coronary artery stenosis. This study provides preliminary evidence showing that there may be significant prognostic value in coronary angiography as a part of the pretransplant workup.

Relationship between MELD severity score and the distance walked and respiratory muscle strength in candidates for liver transplantation

The model end-stage liver disease (MELD) severity scoring system is used in the allocation of organs for liver transplantation. However, there is no evidence of its relationship with the functionality and respiratory muscle strength in these patients. The aim of this study was to analyze the correlation of MELD with distance walked and respiratory muscle strength in patients awaiting liver transplantation. We performed a cross-sectional analysis of 24 individuals (16 male and 8 female) with mean age of 51.8 +/- 10.4 years. The MELD score inversely correlated with the 6-minute walking test (6MWT) (r = -0.85; P < .001) and with the maximal inspiratory pressure (MIP) (r = -0.69; P < .001). In addition, there was a correlation between 6MWT and MIP (r = 0.77; P < .001). Thus, MELD scores can be considered to be effective tools to predict the functional capacity and respiratory muscle strength in candidates for liver transplantation.

Model of end stage liver disease (MELD) score greater than 23 predicts length of stay in the ICU but not mortality in liver transplant recipients

Introduction

The impact of model of end stage liver disease (MELD) score on postoperative morbidity and mortality is still elusive, especially for high MELD. There are reports of poorer patient outcome in transplant candidates with high MELD score, others though report no influence of MELD score on outcome and survival.

Methods

We retrospectively analyzed data of 144 consecutive liver transplant recipients over a 72-month period in our transplant unit, from January 2003 until December 2008 and performed uni- and multivariate analysis for morbidity and mortality, in particular to define the influence of MELD to these parameters.

Results

This study identified MELD score greater than 23 as an independent risk factor of morbidity represented by intensive care unit (ICU) stay longer than 10 days (odds ratio 7.0) but in contrast had no negative impact on mortality. Furthermore, we identified transfusion of more than 7 units of red blood cells as independent risk factor for mortality (hazard ratio 7.6) and for prolonged ICU stay (odds ratio [OR] 7.8) together with transfusion of more than 10 units of fresh frozen plasma (OR 11.6). Postoperative renal failure is a strong predictor of morbidity (OR 7.9) and postoperative renal replacement therapy was highly associated with increased mortality (hazard ratio 6.8), as was hepato renal syndrome prior to transplantation (hazard ratio 13.2).

Conclusions

This study identified MELD score greater than 23 as an independent risk factor of morbidity represented by ICU stay longer than 10 days but in contrast had no negative impact on mortality. This finding supports the transplantation of patients with high MELD score but only with knowledge of increased morbidity.