Correlation between selected prognostic factors and postoperative course in liver transplant recipients

A Retrospective Study of the Role of Perioperative Serum Albumin and the Albumin-Bilirubin Grade in Predicting Post-Liver Transplant Length of Stay

INTRODUCTION

Serum albumin's association with liver transplant outcomes has been investigated with mixed findings. This study aimed to evaluate perioperative albumin level, independently and as part of the albumin-bilirubin (ALBI) grade, as a predictor of post-liver transplant hospital and intensive care unit (ICU) length of stay (LOS).

METHODS

Adult liver-only transplant recipients at our institution from September 2011 to May 2019 were included in this retrospective study. Repeat transplants were excluded. Demographic, laboratory, and hospital course data were extracted from an institutional data warehouse. Negative binomial regression was used to assess the association of LOS with ALBI grade, age, BMI, ASA score, Elixhauser comorbidity index, MELD-Na, warm ischemia time, units of platelets and cryoprecipitate transfused, and preoperative serum albumin.

RESULTS

Six hundred and sixty-three liver transplant recipients met inclusion criteria. The median preoperative serum albumin was 3.1 [2.6-3.6] g/dL. The median postoperative ICU and hospital LOS were 3.8 [2.4-6.8] and 12 [8-20] days, respectively. Preoperative serum albumin predicted hospital but not ICU LOS (ratio .9 [95% confidence interval (CI) .84-.99], P = .03, hospital LOS vs ratio .92 [95% CI 0.84-1.02], P = .10, ICU LOS). For patients with MELD-Na ≤ 20, ALBI grade-3 predicted longer hospital and ICU LOS (ratio 1.40 [95% CI 1.18-1.66], P < .001, hospital LOS vs ratio 1.62 [95% CI 1.32-1.99], P < .001, ICU LOS). These associations were not significant for patients with MELD-Na > 20.

CONCLUSIONS

Serum albumin predicted post-liver transplant hospital LOS. ALBI grade-3 predicted increased hospital and ICU LOS in low MELD-Na recipients.

Laboratory Predictors of COVID-19 Pneumonia in Patients with Mild to Moderate Symptoms

OBJECTIVE

This research aims to develop a laboratory model that can accurately distinguish pneumonia from nonpneumonia in patients with COVID-19 and to identify potential protective factors against lung infection.

METHODS

We recruited 50 patients diagnosed with COVID-19 infection with or without pneumonia. We selected candidate predictors through group comparison and punitive least absolute shrinkage and selection operator (LASSO) analysis. A stepwise logistic regression model was used to distinguish patients with and without pneumonia. Finally, we used a decision-tree method and randomly selected 50% of the patients 1000 times from the same specimen to verify the effectiveness of the model.

RESULTS

We found that the percentage of eosinophils, a high-fluorescence-reticulocyte ratio, and creatinine had better discriminatory power than other factors. Age and underlying diseases were not significant for discrimination. The model correctly discriminated 77.1% of patients. In the final validation step, we observed that the model had an overall predictive rate of 81.3%.

CONCLUSION

We developed a laboratory model for COVID-19 pneumonia in patients with mild to moderate symptoms. In the clinical setting, the model will be able to predict and differentiate pneumonia vs nonpneumonia before any lung computed tomography findings. In addition, the percentage of eosinophils, a high-fluorescence-reticulocyte ratio, and creatinine were considered protective factors against lung infection in patients without pneumonia.

Post Liver Transplantation Survival and Related Prognostic Factors among Adult Recipients in Tehran Liver Transplant Center; 2002-2019

BACKGROUND

Liver transplantation is a standard treatment for patients with end-stage liver disease (ESLD). However, with increasing demand for this treatment and limited resources, it is available only to patients who are more likely to survive. The primary aim was to determine prognostic factors for survival.

METHODS

We collected data from 597 adult patients with ESLD, who received a single organ and initial orthotopic liver transplantation (OLT) in our center between 20 March 2008 and 20 March 2018. In this historical cohort study, univariate and multiple Cox model were used to determine prognostic factors of survival after transplantation.

RESULTS

After a median follow-up of 825 (0-3889) days, 111 (19%) patients died. Survival rates were 88%, 85%, 82% and 79% at 90 days, 1 year, 3 years, and 5 years, respectively. Older patients (HR = 1.27; 95% CI: 1.01-1.59), presence of pre-OLT ascites (HR = 2.03; 95% CI: 1.16-3.57), pre-OLT hospitalization (HR = 1.88; 95% CI:1.02-3.46), longer operative time (HR = 1.006; 95% CI: 1.004-1.008), post-OLT dialysis (HR = 3.51; 95% CI: 2.07-5.94), cancer (HR = 2.69; 95% CI: 1.23-5.89) and AID (HR = 2.04; 95% CI: 1.17-3.56) as underlying disease versus hepatitis, and higher pre-OLT creatinine (HR = 1.67; 95% CI: 1.10-2.52) were associated with decreased survival.

CONCLUSION

In this center, not only are survival outcomes excellent, but also younger patients, cases with better pre-operative health conditions, and those without complications after OLT have superior survival.

Predictors of early recipient mortality after living donor liver transplantation in a tertiary care center in Egypt

BACKGROUND

Living donor liver transplantation (LDLT) has evolved into a widely accepted therapeutic option. Many different risk factors may affect early mortality after LDLT.

OBJECTIVES

Analyze risk factors that can affect early (<6 months) mortality of patients after LDLT in a single center.

DESIGN

Retrospective chart review of patients who underwent LDLT.

SETTING

University hospital.

PATIENTS AND METHODS

Adult cirrhotic patients who underwent LDLT were classified by early (first 6 months) or late mortality. A full pre, intra- and post-operative evaluation had been done on all patients including a full history, examination and investigations to identify risk factors that might affect mortality post-LDLT.

MAIN OUTCOME MEASURES

Determination of pre-, intra- or postoperative factors that might affect recipient mortality post-LDLT.

SAMPLE SIZE

123.

RESULTS

Pre-operative factors that increased early mortality in a univariate analysis were higher model for end-stage liver disease (MELD) scores, lower graft-recipient weigh ratio (GRWR), older donor age, and recurrent spontaneous bacterial peritonitis. Intraoperative factors included more transfusion units of blood, plasma, platelets and cryoprecipitate, a longer time for cold and warm ischemia, and a longer anhepatic phase among others. Postoperative factors included a longer ICU or hospital stay and abnormal postoperative laboratory data. In the final logistic regression model, the most significant factors were pre-operative GRWR, length of hospital stay, units of intraoperative blood transfusion, postoperative alanine aminotransferase, postoperative total leukocyte count, and MELD score.

CONCLUSION

LDLT outcomes might be improved by attempting to resolve clinical factors that have been identified as contributors to early post-LDLT mortality.

LIMITATIONS

More risk factors, such as those relevant to patient portal vein hemodynamics, should be included in an analysis of predictors of early mortality.

CONFLICT OF INTEREST

None.

Long-term Outcomes and Risk Factors After Adult Living Donor Liver Transplantation

BACKGROUND

Although risk factors for the long-term mortality of liver transplantation are well described, there is a lack of detailed study regarding these factors for adult living donor liver transplantation (LDLT).

METHODS

We retrospectively analyzed 528 adult LDLT recipients in our hospital. The risk factors were analyzed for overall deaths more than 5 years post-LDLT.

RESULTS

Over the 20-year follow-up, 137 patients died. Patient survival at 1, 3, 5, and 10 years post-LDLT was 87.8%, 81.8%, 79.4%, and 72.8%, respectively. The independent risk factors for more than 5 years post-LDLT overall death were hepatocellular carcinoma recurrence (hazard ratio [HR], 38.9; P < 0.001), lymphoid de novo malignancy (HR, 47.2; P = 0.001), primary sclerosing cholangitis as primary diagnosis (HR, 11.5; P < 0.001), chronic rejection (HR, 6.93; P = 0.006), acute rejection (HR, 2.96; P = 0.017), and bile duct stenosis (HR, 2.30; P = 0.045).

CONCLUSIONS

Not only malignancies and rejection but also bile duct stenosis and primary sclerosing cholangitis had significant impacts on late period post-LDLT mortality.

Factors associated with long-term survival after liver transplantation: A retrospective cohort study

AIM

To identify predictive factors associated with long-term patient and graft survival (> 15 years) in liver transplant recipients.

METHODS

Medical charts of all de novo adult liver transplant recipients (n = 140) who were transplanted in Hamburg between 1997 and 1999 were retrospectively reviewed. In total, 155 transplantations were identified in this time period (15 re-transplantations). Twenty-six orthotopic liver transplant (OLT) recipients were early lost to follow-up due to moving to other places within 1 year after transplantation. All remaining 114 patients were included in the analysis. The following recipient factors were analysed: Age, sex, underlying liver disease, pre-OLT body mass index (BMI), and levels of alanine aminotransferase (ALT), bilirubin, creatinine and gamma-glutamyltransferase (gamma-GT), as well as warm and cold ischemia times. Furthermore, the following donor factors were assessed: Age, BMI, cold ischemia time and warm ischemia time. All surviving patients were followed until December 2014. We divided patients into groups according to their underlying diagnosis: (1) hepatocellular carcinoma (n = 5, 4%); (2) alcohol toxic liver disease (n = 25, 22.0%); (3) primary sclerosing cholangitis (n = 6, 5%); (4) autoimmune liver diseases (n = 7, 6%); (5) hepatitis C virus cirrhosis (n = 15, 13%); (6) hepatitis B virus cirrhosis (n = 21, 19%); and (7) other (n = 35, 31%). The group “other” included rare diagnoses, such as acute liver failure, unknown liver failure, stenosis and thrombosis of the arteria hepatica, polycystic liver disease, Morbus Osler and Caroli disease.

RESULTS

The majority of patients were male (n = 70, 61%). Age and BMI at the time point of transplantation ranged from 16 years to 69 years (median: 53 years) and from 15 kg/m² to 33 kg/m² (median: 24), respectively. Sixty-six OLT recipients (58%) experienced a follow-up of 15 years after transplantation. Recipient’s age (P = 0.009) and BMI (P = 0.029) were identified as risk factors for death by χ²-test. Kaplan-Meier analysis confirmed BMI or age above the median as predictors of decreased long-term survival (P = 0.008 and P = 0.020). Hepatitis B as underlying disease showed a trend for improved long-term survival (P = 0.049, χ²-test, P = 0.055; Kaplan-Meier analysis, Log rank). Pre-transplant bilirubin, creatinine, ALT and gamma-GT levels were not associated with survival in these patients of the pre-era of the model of end stage liver disease.

CONCLUSION

The recipients’ age and BMI were predictors of long-term survival after OLT, as well as hepatitis B as underlying disease. In contrast, donors’ age and BMI were not associated with decreased survival. These findings indicate that recipient factors especially have a high impact on long-term outcome after liver transplantation.

Post-operative hypertension, a surrogate marker of the graft function and predictor of survival in living donor liver transplant recipients: A retrospective study

BACKGROUND AND AIMS

De novo hypertension (HTN) in liver transplantation recipients is a known entity. We investigated haemodynamic behaviour after a liver transplant to see if it can predict survival to discharge from the hospital.

METHODS

electronic records of Haemodynamic parameters and laboratory investigations of 95 patients of living donor liver transplant (LDLT) were retrospectively analysed.

RESULTS

Twenty-three patients were operated for acute liver failure (ALF) and 72 patients for chronic liver disease (CLD). Eight patients of CLD and four of ALF did not survive. CLD patients had statistically significant rise in systolic blood pressure from the post-operative day (POD) 1 to POD 4 and diastolic blood pressure (DBP) from POD 3 to POD 6. Heart rate (HR) significantly decreased from POD 3 to POD 5. Haemodynamic parameters returned to baseline values within 20 days. Diastolic HTN had a positive predictive value of 100% for survival with 100% sensitivity and specificity. Systolic HTN had a positive predictive value of 100% for survival (sensitivity-89%, specificity-100%). ALF patients had a significant decrease in HR from POD 2 to POD 10. Bradycardia (HR ≤60/min) had a positive predictive value of 100% for survival with a sensitivity of 45% and 58% in CLD and ALF, respectively, with a specificity of 100% in both the groups. Non-survivors had no significant change in haemodynamics. In CLD group, International Normalised Ratio had statistically significant, strong negative correlation with DBP.

CONCLUSION

Haemodynamic pattern of recovery may be used for predicting survival to discharge after LDLT.

Analysis of the survival of cirrhotic patients enlisted for liver transplantation in the pre- and post-MELD era in southern Brazil

CONTEXT

Transplantation is the only cure for decompensated cirrhosis. Model for End-Stage Liver Disease (MELD) is used in liver allocation.

OBJECTIVES

Comparing survival of enlisted populations in pre- and post-MELD eras and estimating their long-term survival.

METHODS

This is a retrospective study of cirrhotics enlisted for transplantation during pre- and post-MELD eras. Survival curves were generated using Kaplan-Meier's model. Cox's model was used to determine risk factors for mortality. Exponential, Weibull's, normal-log and Gompertz's models were used to estimate long-term survival.

RESULTS

The study included 162 patients enlisted in pre-MELD era and 184 in post-MELD period. Kaplan-Meier's survival curve of patients enlisted in post-MELD era was better than that of pre-MELD period (P = 0.009). This difference remained for long-term estimates, with a survival of 53.54% in 5 years and 44.64% in 10 years for patients enlisted in post-MELD era and of 43.17% and 41.75% for pre-MELD period. Era in which patients had been enlisted (P = 0.010) and MELD score at enlistment (P<0.001) were independently associated to survival with hazard ratios of 0.664 (95% CI-confidence interval = 0.487-0.906) and 1.069 (95% CI = 1.043-1.095).

CONCLUSIONS

MELD-based transplantation policy is superior to chronology-based one, promoting better survival for enlisted patients, even in long-term.

Renal support during liver transplantation: when to consider it?

Patients undergoing orthotopic liver transplantation constitute a difficult-to-treat population. They often have multiorgan dysfunction: acute kidney injury, severe water-electrolyte and acid-base imbalances, systemic inflammatory responses, thrombocytopenia, as well as abnormalities of coagulation and fibrinolysis. All of these disorders may be further exacerbated by the surgical procedure, which is lengthy and technically complex, requiring massive blood product and other fluid infusions with a high risk to develop severe lactic acidosis, hyperkalemia, or cerebral edema. These considerations provide a rationale to institute intraoperative renal replacement therapy (ioRRT), at least for the most critically ill, namely, patients with kidney dysfunction, or those in whom one anticipates intraoperative clinical and technical problems. This article discusses the most common indications and strategies for ioRRT, examining their advantages and disadvantages as well as current experiences.

Oil Red O-assessed macrosteatosis in liver transplant donor biopsies predicts ischemia-reperfusion injury and clinical outcome

Steatosis in donor livers is an accepted adverse prognostic factor after liver transplantation. While its semiquantitative assessment shows varying reproducibility, it is questioned as a standard method. Additionally, the influence of hepatic steatosis on ischemia/reperfusion injury (I/R injury) has not been evaluated in biopsies after reperfusion. We compared different staining and analyzing methods for the assessment of donor liver steatosis in order to predict I/R injury and clinical outcome after transplantation. To do this, 56 paired pre- and post-reperfusion liver biopsies were analyzed for macro- (MaS)/micro- (MiS) and total steatosis in cryo and permanent sections by special fat (Oil Red O or ORO) and standard stains. Computerized morphometrical analyses were compared to the semiquantitative assessment by a pathologist. I/R injury was determined histopathologically and by M30 immunohistochemistry. We found ORO to be more sensitive in detecting hepatic steatosis with higher reproducibility for MaS. Semiquantitative analyses were highly reproducible and not inferior to computerized morphometry. Categorized MaS as determined by ORO correlated with the extent of I/R injury, initial poor function, liver enzymes, and survival. Therefore fat stains like ORO are a reliable and easy method comprising significant advantages in the evaluation of hepatic steatosis and are thereby of prognostic value. Computerized analysis is a precise tool though not superior to semiquantitative analyses.

The association between cytokine gene polymorphisms and graft rejection in liver transplantation: a systematic review and meta-analysis

We investigated the contribution of polymorphisms in cytokine genes (TNFa-308, IL10-1082 and -592, TGFb1-c10 and c25, and IFNg+874) on the risk of graft rejection in liver transplantation. We performed a systematic review by identifying relevant studies and applied meta-analysis to pool gene effects. In total, 12 studies were eligible and included in the study. Data extraction and assessments for risk of bias were independently performed by two reviewers. Data for allele frequencies, allelic, and genotypic effects were pooled. Heterogeneity and publication bias were assessed. Pooled minor allele frequencies for TNFa-308, IL10-1082, TGFb1-c10, TGFb1-c25, IFNg+874, and IL10-592 were 0.140 (95% CI: 0.083, 0.198), 0.432 (95% CI: 0.392, 0.472), 0.387 (95% CI: 0.307, 0.467), 0.090 (95% CI: 0.056, 0.123), 0.460 (95% CI: 0.392, 0.528), and 0.224 (95% CI: 0.178, 0.269), respectively. OnlyTNFa-308 and IL10-1082 polymorphisms were significantly associated with graft rejection. Patients who carried minor homozygous genotypes for these two polymorphisms were at 3.5 and 1.69 times higher risk of graft rejections than patients who carried major homozygous genotypes. The estimated lambdas were 0.41 and 0.47, suggesting an additive mode of effect was most likely. However, we could not detect the associations of TGFb1at c10 and c25, INFg+874, and IL10-592 polymorphisms and graft rejection. In summary, our systematic review has demonstrated that TNFa-308 and IL10-1082 are potential risk factors of poor outcomes in liver transplantation. Future updated meta-analysis studies to confirm the power of these genotypes in association with allograft rejection are needed.