Indications for and survival after liver retransplantation

LIVER RETRANSPLANTATION: PROGNOSTIC SCORES AND RESULTS IN THE STATE OF PARANÁ

BACKGROUND

Hepatic retransplantation is associated with higher morbidity and mortality when compared to primary transplantation. Given the scarcity of organs and the need for efficient allocation, evaluating parameters that can predict post-retransplant survival is crucial.

AIMS

This study aimed to analyze prognostic scores and outcomes of hepatic retransplantation.

METHODS

Data on primary transplants and retransplants carried out in the state of Paraná in 2019 and 2020 were analyzed. The two groups were compared based on 30-day survival and the main prognostic scores of the donor and recipient, namely Model for End-Stage Liver Disease (MELD), MELD-albumin (MELD-a), Donor MELD (D-MELD), Survival Outcomes Following Liver Transplantation (SOFT), Preallocation Score to Predict Survival Outcomes Following Liver Transplantation (P-SOFT), and Balance of Risk (BAR).

RESULTS

A total of 425 primary transplants and 30 retransplants were included in the study. The main etiology of hepatopathy in primary transplantation was ethylism (n=140; 31.0%), and the main reasons for retransplantation were primary graft dysfunction (n=10; 33.3%) and hepatic artery thrombosis (n=8; 26.2%). The 30-day survival rate was higher in primary transplants than in retransplants (80.5% vs. 36.7%, p=0.001). Prognostic scores were higher in retransplants than in primary transplants: MELD 30.6 vs. 20.7 (p=0.001); MELD-a 31.5 vs. 23.5 (p=0.001); D-MELD 1234.4 vs. 834.0 (p=0.034); SOFT 22.3 vs. 8.2 (p=0.001); P-SOFT 22.2 vs. 7.8 (p=0.001); and BAR 15.6 vs. 8.3 (p=0.001). No difference was found in terms of Donor Risk Index (DRI).

CONCLUSIONS

Retransplants exhibited lower survival rates at 30 days, as predicted by prognostic scores, but unrelated to the donor's condition.

Relationship of Anatomic Variations and Arterial Reconstruction of the Hepatic Artery: Prevalence and Effect on Orthotopic Liver Transplantation

BACKGROUND

Identifying anatomic variations of the hepatic artery is essential in liver transplantation. The artery supply is crucial for the procedure's success, and, in some cases of anatomic variations, they need reconstruction. Hepatic artery thrombosis is a severe vascular complication. This study evaluated the prevalence of anatomic variations and correlated arterial reconstructions with hepatic artery thrombosis.

METHODS

We performed a retrospective analysis of medical records, adult patients undergoing liver transplant, donor's arterial anatomy, arterial reconstructions, and thrombosis after transplant from January 2019 to December 2020.

RESULTS

Among 226 cases, 71% had normal anatomy. All these patients met Michel's classification subtypes, of which 161 (71%) were class I, which is the most common. The second most common variation was class II, with 25 donors (11%), followed by class III, with 17 donors (7.5%). Anatomic artery variations were a risk factor for hepatic artery thrombosis development (odds ratio [OR], 7.2; 95% confidence interval [CI], 2.1-22.5; P = .002). In the same way, the artery reconstruction was associated with hepatic artery thrombosis arising with postoperative time (OR, 18.0; 95% CI, 4.9-57.5; P < .001). Global hepatic artery thrombosis occurred in 11 cases (4.87%).

CONCLUSION

Anatomic hepatic artery variations are frequent and do not make liver transplant unfeasible. However, variations that require reconstruction may raise the risk of thrombosis.

Adults transplanted as children as retransplant candidates: Analysis of outcomes support optimism in a population mislabeled as high risk

Adult liver transplant programs have heretofore been hesitant to perform liver retransplantation in adult patients who underwent primary liver transplantation as a child (P_A). Areas of concern include: (a) potential disruption in care when transferring from a pediatric to an adult transplant center; (b) generally inferior outcomes of retransplantation; (c) reputation of young adults for non-adherence to post-transplant regimen; and (d) potential higher work effort for equivalent outcomes. To examine these concerns, we reviewed data on all US liver adult retransplants from 10/01/1987 to 9/30/2017. We propensity matched the P_A patients to patients who received both primary and retransplantation as adults (A_A), with ≥550 days between transplants. A mixed Cox proportional hazards model with program size and time period of transplantation as random variables revealed that retransplantation of P_A patients produced no significantly different graft survival or patient survival rates than retransplantation of the matched A_A patients. Therefore, inferior rates of liver retransplantation in these patients and concerns about continuity of care in changing transplant programs are not as believed in the wider liver transplant community. In conclusion, liver transplant centers should be optimistic about retransplanting adults who received their primary transplants as children.

VI consensus document by the Spanish Liver Transplantation Society

The goal of the Spanish Liver Transplantation Society (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, on October 20, 2016, the 6th Consensus Document Meeting was held, with the participation of experts from the 24 authorized Spanish liver transplantation programs. This Edition discusses the following subjects, whose summary is offered below: 1) limits of simultaneous liver-kidney transplantation; 2) limits of elective liver re-transplantation; and 3) liver transplantation after resection and hepatocellular carcinoma with factors for a poor prognosis. The consensus conclusions for each of these topics is provided below.

Retransplant of the Liver: 12-Year Experience of the Shiraz Organs Transplantation Center

OBJECTIVES

Liver transplant is the most effective treatment modality for patients with end-stage liver disease, metabolic disorders, hepatic malignancy, and acute liver failure. When a graft fails after primary liver transplant, retransplant of the liver remains the only option. Here, we report the past 12-year experience of the Shiraz Transplant Center regarding liver retransplant.

MATERIALS AND METHODS

This is a retrospective cohort study of a 12-year period (2004-2015) of the Shiraz Center in Iran.

RESULTS

Of the 3107 patients who had a liver transplant during the study period, 58 retransplants were performed (1.86%) in 57 patients. The leading cause of retransplant was primary nonfunction in 24 patients (41.4% of retransplant cases and 0.77% of all liver transplant cases). The second leading cause of retransplant was vascular complications in 25 patients (23 with hepatic artery thrombosis and 2 with portal vein thrombosis), accounting for 43.1% of retransplant cases and 0.80% of all liver transplant cases. In addition, 5 patients (8.6%) had retransplant for rejection, which accounted for 0.16% of all liver transplant cases. Four patients with retransplant (6.9%) had recurrence of primary disease, which accounted for 0.12% of all liver transplant cases. Most liver retransplants occurred early (≤ 30 days after primary transplant) at the Shiraz Transplant Center. Five-year survival rate after retransplant was 35%, and retransplant for hepatic artery thrombosis was more common in children.

CONCLUSIONS

Because most patients required retransplants in the early period after primary transplant, the decision for retransplant must be considered carefully with full multidisciplinary evaluation and only in skilled hands. Retransplant in subgroups of patients with little chance of a successful outcome should be avoided.

VI consensus document by the Spanish Liver Transplantation Society

The goal of the Spanish Liver Transplantation Society (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, on October 20, 2016, the 6th Consensus Document Meeting was held, with the participation of experts from the 24 authorized Spanish liver transplantation programs. This Edition discusses the following subjects, whose summary is offered below: 1) limits of simultaneous liver-kidney transplantation; 2) limits of elective liver re-transplantation; and 3) liver transplantation after resection and hepatocellular carcinoma with factors for a poor prognosis. The consensus conclusions for each of these topics is provided below.

Early Vs Late Liver Retransplantation: Different Characteristics and Prognostic Factors

BACKGROUND

East Asia is a known endemic area for hepatitis B, and living donor liver transplantation is mainly performed. Liver retransplantation (ReLT) is expected to become an increasing problem because of a shortage of organs. This study aimed to compare early and late ReLT with consideration of specific circumstances and disease background of East Asians.

METHODS

Between October 1996 and January 2015, 51 patients underwent ReLT; we performed a retrospective analysis of data obtained from medical records of the patients. Clinical characteristics, indication, causes of death, survival rate, and prognostic factors were investigated.

RESULT

The survival rate for early ReLT (n = 18) was 51.5% and that for late ReLT (n = 33) was 50.1% at 1 year postoperatively. Continuous venovenous hemodialysis and the use of mechanical ventilators were more frequent, and pre-retransplant intensive care unit stay and prothrombin time was longer in early ReLT than in late ReLT. Operation time was longer and the amount of intraoperative blood loss was greater in late ReLT than in early ReLT. Multivariate analysis showed that a higher C-reactive protein level increased mortality in early ReLT (P = .045), whereas a higher total bilirubin level increased the risk of death in late ReLT (P = .03).

CONCLUSION

Patients with early ReLT are likely to be sicker pre-retransplantation and require adequate treatment of the pretransplant infectious disease. On the other hand, late ReLT is likely to be technically more difficult and should be decided before the total bilirubin level increases substantially.

Nonvascular post-liver transplantation complications: from US screening to cross-sectional and interventional imaging

Orthotopic liver transplantation is becoming an increasingly routine procedure for a variety of benign and malignant diseases of the liver and biliary system. Continued improvements in surgical techniques and post-transplantation immunosuppression regimens have resulted in better graft and patient survival. A number of potentially treatable nonvascular complications of liver transplantation are visible at imaging, and accurate diagnosis of these complications allows patients to benefit from potential treatment options. Biliary complications include stricture (anastomotic and nonanastomotic), leak, biloma formation, and development of intraductal stones. Pathologic conditions, including hepatitis C infection, hepatocellular carcinoma, hepatic steatosis, and primary sclerosing cholangitis, may recur after liver transplantation. Transplant patients are at increased risk for developing de novo malignancy, including post-transplantation lymphoproliferative disorder, which results from immunosuppression. Patients are also at increased risk for systemic infection from immunosuppression, and patients with hepatic artery and biliary complications are at increased risk for liver abscess. Transplant recipients are typically followed with serial liver function testing; abnormal serum liver function test results may be the first indication that there is a problem with the transplanted liver. Ultrasonography is typically the first imaging test performed to try to identify the cause of abnormal liver function test results. Computed tomography, magnetic resonance imaging, angiography, and/or cholangiography may be necessary for further evaluation. Accurately diagnosing nonvascular complications of liver transplantation that are visible at imaging is critically important for patients to benefit from appropriate treatment.

Management of early hepatic artery occlusion after liver transplantation with failed rescue

Hepatic artery thrombosis is a serious complication after liver transplantation which often results in biliary complications, early graft loss, and patient death. It is generally thought that early hepatic artery thrombosis without urgent re-vascularization or re-transplantation almost always leads to mortality, especially if the hepatic artery thrombosis occurs within a few days after transplantation. This series presents 3 cases of early hepatic artery thrombosis after living donor liver transplantation, in which surgical or endovascular attempts at arterial re-vascularization failed. Unexpectedly, these 3 patients survived with acceptable graft function after 32 mo, 11 mo, and 4 mo follow-up, respectively. The literatures on factors affecting this devastating complication were reviewed from an anatomical perspective. The collective evidence from survivors indicated that modified nonsurgical management after liver transplantation with failed revascularization may be sufficient to prevent mortality from early hepatic artery occlusion. Re-transplantation may be reserved for selected patients with unrecovered graft function.

Predictive factors of neurological complications and one-month mortality after liver transplantation

Background: Neurological complications are common after orthotopic liver transplantation (OLT). We aimed to characterize the risk factors associated with neurological complications and mortality among patients who underwent OLT in the post-model for end-stage liver disease (MELD) era.

Methods: In a retrospective review, we evaluated 227 consecutive patients at the Keck Hospital of the University of Southern California before and after OLT to define the type and frequency of and risk factors for neurological complications and mortality.

Results: Neurological complications were common (n = 98), with encephalopathy being most frequent (56.8%), followed by tremor (26.5%), hallucinations (11.2%), and seizure (8.2%). Factors associated with neurological complications after OLT included preoperative dialysis, hepatorenal syndrome, renal insufficiency, intra-operative dialysis, preoperative encephalopathy, preoperative mechanical ventilation, and infection. Preoperative infection was an independent predictor of neurological complications (OR 2.83, 1.47–5.44). One-month mortality was 8.8% and was independently associated with urgent re-transplant, preoperative intubation, and intra-operative arrhythmia.

Conclusion: Neurological complications are common in patients undergoing OLT in the post-MELD era, with encephalopathy being most frequent. An improved understanding of the risk factors related to both neurological complications and one-month mortality post-transplantation can better guide perioperative care and help improve outcomes among OLT patients.

Natural history, treatment and prevention of hepatitis C recurrence after liver transplantation: Past, present and future

Hepatitis C virus (HCV)-related liver disease, including cirrhosis and hepatocellular carcinoma is the main indication for liver transplantation (LT) worldwide. Post-transplant HCV re-infection is almost universal and results in accelerated progression from acute hepatitis to chronic hepatitis, and liver cirrhosis. Comprehension and treatment of recurrent HCV infection after LT have been major issues for all transplant hepatologists and transplant surgeons for the last decades. The aim of this paper is to review the evolution of our knowledge on the natural history of HCV recurrence after LT, including risk factors for disease progression, and antiviral therapy. We will focus our attention on possible ways (present and future) to improve the final long-term results of LT for HCV-related liver disease.

Hepatic artery ligation for arterial rupture following liver transplantation: a reasonable option

Hepatic artery (HA) rupture after liver transplantation is a rare complication with high mortality. This study aimed to review the different managements of HA rupture and their results. From 1997 to 2007, data from six transplant centers were reviewed. Of 2649 recipients, 17 (0.64%) presented with HA rupture 29 days (2-92) after transplantation. Initial management was HA ligation in 10 patients, reanastomosis in three, aorto-hepatic grafting in two and percutaneous arterial embolization in one. One patient died before any treatment could be initiated. Concomitant biliary leak was present in seven patients and could be subsequently treated by percutaneous and/or endoscopic approaches in four patients. Early mortality was not observed in patients with HA ligation and occurred in 83% of patients receiving any other treatment. After a median follow-up of 70 months, 10 patients died (4 after retransplantation), and 7 patients were alive without retransplantation (including 6 with HA ligation). HA ligation was associated with better 3-year survival (80% vs. 14%; p=0.002). Despite its potential consequences on the biliary tract, HA ligation should be considered as a reasonable option in the initial management for HA rupture after liver transplantation. Unexpectedly, retransplantation was not always necessary after HA ligation in this series.

Intraoperative hepatic artery blood flow predicts early hepatic artery thrombosis after liver transplantation

Hepatic artery complications after orthotopic liver transplantation are associated with a high rate of graft loss and mortality (23% to 35%) because they can lead to liver ischemia. The reported incidence of hepatic artery thrombosis (HAT) after adult liver transplantation is 2.5% to 6.8%. Typically, these patients are treated with urgent surgical revascularization or emergent liver retransplantation. Since January 2007, we have recorded the postanastomotic hepatic artery flow after revascularization. The aim of this study was to assess the relationship between hepatic blood flow on revascularization and early HAT. Retrospectively, we reviewed perioperative variables from 110 consecutive liver transplantation performed at the Virgen del Rocío University Hospital (Seville, Spain) between January 2007 and October 2010. We evaluated the following preoperative (donor and recipient) and intraoperative variables: donor and recipient age, cytomegalovirus serology, ABO-compatibility, anatomical variations of the donor hepatic artery, number of arterial anastomoses, portal and hepatic artery flow before closure, cold ischemia time, and blood transfusion. These variables were included in a univariate analysis. Of the 110 patients included in the study, 85 (77.7%) were male. The median age was 52 years. ABO blood groups were identical between donor and recipient in all the patients. The prevalence of early HAT was 6.36% (7 of 110). Crude mortality with/without HAT was 22% versus 2% (P = .001), respectively. Crude graft loss rate with/without HAT was 27% versus 4% (P = .003), respectively. Early HAT was shown to be primarily associated with intraoperative hepatic artery blood flow (93.3 mL/min recipients with HAT versus 187.7 mL/min recipients without HAT, P < .0001). No retransplantation showed early HAT. In our experience, intraoperative hepatic artery blood flow predicts early HAT after liver transplantation.

A score predicting survival after liver retransplantation for hepatitis C virus cirrhosis

BACKGROUND

Approximately one fourth of patients transplanted for hepatitis C virus (HCV)-induced liver failure progress to cirrhosis within 5 years, potentially requiring retransplantation. Although the relisting decision can be difficult in these patients, a score could help in selection of candidates with the best potential outcomes.

METHODS

A total of 1422 HCV-positive patients having undergone a retransplantation were included in this registry-based study. A multivariate Cox regression was performed, and an Akaike procedure was applied to design a score predicting survival after retransplantation and to allow an internal validation. Retained variables were donor age (DnAge), serum creatinine (Creat), International Normalized Ratio (INR), and serum albumin (Alb) at the second transplantation, recipient age (RecAge) at the first transplantation, and the interval between both transplantations (Int).

RESULTS

The score was designed as 0.23×DnAge+4.86×log Creat-2.45×log Int+2.69×INR+0.10×RecAge-3.27× Alb+40. The receiver operating characteristic area under curve was 0.643 at 3 years, and survivals were 71%, 56%, and 37% for scores <30, 30 to 40, and >40, respectively (log rank <0.0001).

CONCLUSIONS

Overall, the proposed score is specifically designed for HCV-positive patients, accurately predicts survival after a liver retransplantation, and is helpful in the selection of candidates with the best potential outcomes.

Non-anastomotic biliary strictures after liver transplantation: Focus on percutaneous treatment and extent of disease

Introduction: Biliary strictures remain a key problem after liver transplantation. Anastomotic strictures are treated by surgery or interventional therapy. Intrahepatic stenosis requires retransplantation. For bridging, percutaneous and endoscopic interventions are used. The extent of the strictures may have an important role in therapy planning. Methods: Strictures were divided into four zones (1: extrahepatic, not included in this study; 2: hilar; 3: central; 4: peripheral). Twenty patients were treated with balloon dilatation/stent implantation/retransplantation/supportive care (Zone 1: 0/0/0/0; Zone 2: 8/7/2/0; Zone 3: 7/5/2/1; Zone 4: 1/1/3/1). Results: Mean follow-up time was 48 months. In Zone 2, one patient died as a result of recurrent hepatocellular carcinoma (HCC), and seven patients are alive, five after stent placements and two after retransplantation. Four patients are alive in Zone 3: all had stent placements and one later retransplantation. One patient died after retransplantation, two on the waiting list, and one due to chronic liver failure. One patient is alive in Zone 4 after early retransplantation, and three died. Conclusion: Percutaneous therapy is safe and effective in intrahepatic biliary stenosis after liver transplantation. It can provide the cure or bridge retransplantation. Based on zonal classification, we recommend the following treatments: Zone 4: early retransplantation; Zone 2: minimally invasive therapy; Zone 3: individual decisions.

Major challenges limiting liver transplantation in the United States

Liver transplantation is the gold standard of care in patients with end-stage liver disease and those with tumors of hepatic origin in the setting of liver dysfunction. From 1988 to 2009, liver transplantation in the United States grew 3.7-fold from 1713 to 6320 transplants annually. The expansion of liver transplantation is chiefly driven by scientific breakthroughs that have extended patient and graft survival well beyond those expected 50 years ago. The success of liver transplantation is now its primary obstacle, as the pool of donor livers fails to keep pace with the growing number of patients added to the national liver transplant waiting list. This review focuses on three major challenges facing liver transplantation in the United States and discusses new areas of investigation that address each issue: (1) the need for an expanded number of useable donor organs, (2) the need for improved therapies to treat recurrent hepatitis C after transplantation and (3) the need for improved detection, risk stratification based upon tumor biology and molecular inhibitors to combat hepatocellular carcinoma.

Intensive care management of liver transplanted patients

Advances in pre-transplant treatment of cirrhosis-related organ dysfunction, intraoperative patient management, and improvements in the treatment of rejection and infections have made human liver transplantation an effective and valuable option for patients with end stage liver disease. However, many important factors, related both to an increasing "marginality" of the implanted graft and unexpected perioperative complications still make immediate post-operative care challenging and the early outcome unpredictable. In recent years sicker patients with multiple comorbidities and organ dysfunction have been undergoing Liver transplantation; appropriate critical care management is required to support prompt graft recovery and prevent systemic complications. Early post-operative management is highly demanding as significant changes may occur in both the allograft and the "distant" organs. A functioning transplanted liver is almost always associated with organ system recovery, resulting in a new life for the patient. However, in the unfortunate event of graft dysfunction, the unavoidable development of multi-organ failure will require an enhanced level of critical care support and a prolonged ICU stay. Strict monitoring and sustainment of cardiorespiratory function, frequent assessment of graft performance, timely recognition of unexpected complications and the institution of prophylactic measures to prevent extrahepatic organ system dysfunction are mandatory in the immediate post-operative period. A reduced rate of complications and satisfactory outcomes have been obtained from multidisciplinary, collaborative efforts, skillful vigilance, and a thorough knowledge of pathophysiologic characteristics of the transplanted liver.