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Ayvazoğlu Soy EH, Akdur A, Karakaya E, Moray G, Haberal M. Liver Transplant Recipients Who Survive for More Than 10 Years: A Long-Term Survey. EXP CLIN TRANSPLANT 2022; 20:20-23. [PMID: 35384803 DOI: 10.6002/ect.mesot2021.o8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Liver transplant is the gold standard treatment for end-stage liver failure. Short-term and midterm surveys have been published, but there are few long-term surveys. Here, we report the outcomes of our long-term liver transplant survivors. MATERIALS AND METHODS Since 1988, we have performed 694 liver transplants (366 adult, 328 pediatric), including the first deceased donor transplant in Turkey (December 8, 1988); the first pediatric segmental living related transplant in Turkey, the Middle and Near East, and Europe; the world's first adult segmental living related transplant (April 24, 1990); and the world's first living related donor combined liver-kidney transplant (May 16, 1992). We retrospectively evaluated data from recipients who survived >10 years with normal graft function. RESULTS Of 215 recipients, survival ranges were ≥20 years (n = 13), 15 to 19 years (n = 86), and 10 to 14 years (n = 116); 211 remain alive today with normal liver function. There were 5 retransplants to treat chronic graft rejection, of which 4 recipients are alive with normal graft function after a second liver transplant (15, 20, 22, and 31 years after first transplant). One patient died soon after the second liver transplant (15 years after first transplant). Acute rejection episodes were seen in 72 (34%), and 7 were steroid resistant. There were 48 (22.7%) drug-induced complications. Ten patients had de novo malignancy: 5 lymphoma, 2 squamous cell carcinoma, 1 gastrointestinal stromal tumor, 1 thyroid papillary carcinoma, and 1 multiple myeloma. There were also 31 patients with hepatocellular carcinoma before liver transplant: 13 were beyond Milan criteria, 6 had incidental HCC, and 12 were within Milan. CONCLUSIONS Long-term survival after liver transplant is possible with expert care. Few reports have mentioned long-term surveys; our long-term liver transplant survey is among the largest series in the literature.
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Affiliation(s)
- Ebru H Ayvazoğlu Soy
- From the General Surgery Department, Division of Transplantation, Baskent University, Ankara, Turkey
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2
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Kaltenmeier C, Jorgensen D, Dharmayan S, Ayloo S, Rachakonda V, Geller DA, Tohme S, Molinari M. The liver transplant risk score prognosticates the outcomes of liver transplant recipients at listing. HPB (Oxford) 2021; 23:927-936. [PMID: 33189566 PMCID: PMC8110600 DOI: 10.1016/j.hpb.2020.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/20/2020] [Accepted: 10/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND We assessed if the risk of post-liver transplant mortality within 24 h could be stratified at the time of listing using the liver transplant risk score (LTRS). Secondary aims were to assess if the LTRS could stratify the risk of 30-day, 1-year mortality, and survival beyond the first year. METHODS MELD, BMI, age, diabetes, and the need for dialysis were the five variables used to calculate the LTRS during patients' evaluation for liver transplantation. Mortality rates at 24 h, 30 days, and 1-year were compared among groups of patients with different LTRS. Patients with ABO-incompatibility, redo, multivisceral, partial graft and malignancies except for hepatocellular carcinoma were excluded. Data of 48,616 adult liver transplant recipients were extracted from the Scientific Registry of Transplant Recipients between 2002 and 2017. RESULTS 24-h mortality was 0.9%, 1.0%, 1.1%, 1.7%, 2.3%, 2.0% and 3.5% for patients with LTRS of 0,1,2,3,4, 5 and ≥ 6, respectively (P < 0.001). 30-day mortality was 3.5%, 4.2%, 4.9%, 6.2%, 7.6%, 7.2% and 10.1% respectively (P < 0.001). 1-year mortality was 8.6%, 10.8%, 12.9%, 13.9%, 18.5%, 20.3% and 28.6% respectively (P < 0.001). 10-year survival was 61%, 56%, 57%, 54%, 47%, and 31% for patients with 0, 1, 2, 3, 4, 5 and ≥ 6 points respectively (P < 0.001). CONCLUSION Perioperative mortality and long-term survival of patients undergoing LT can be accurately estimated at the time of listing by the LTRS.
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Affiliation(s)
| | - Dana Jorgensen
- Department of Surgery (Statistics), University of Pittsburgh, Pittsburgh, PA
| | | | - Subhashini Ayloo
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | | | - David A. Geller
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Samer Tohme
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Preoperative Stratification of Liver Transplant Recipients: Validation of the LTRS. Transplantation 2021; 104:e332-e341. [PMID: 32675743 DOI: 10.1097/tp.0000000000003353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The liver transplant risk score (LTRS) was developed to stratify 90-day mortality of patients referred for liver transplantation (LT). We aimed to validate the LTRS using a new cohort of patients. METHODS The LTRS stratifies the risk of 90-day mortality of LT recipients based on their age, body mass index, diabetes, model for end-stage liver disease (MELD) score, and need for dialysis. We assessed the performance of the LTRS using a new cohort of patients transplanted in the United States between July 2013 and June 2017. Exclusion criteria were age <18 years, ABO incompatibility, redo or multivisceral transplants, partial grafts, malignancies other than hepatocellular carcinoma and fulminant hepatitis. RESULTS We found a linear correlation between the number of points of the LTRS and 90-day mortality. Among 18 635 recipients, 90-day mortality was 2.7%, 3.8%, 5.2%, 4.8%, 6.7%, and 9.3% for recipients with 0, 1, 2, 3, 4, and ≥5 points (P < 0.001). The LTRS also stratified 1-year mortality that was 5.5%, 7.7%, 9.9%, 9.3%, 10.8%, and 15.4% for 0, 1, 2, 3, 4, and ≥5 points (P < 0.001). An inverse correlation was found between the LTRS and 4-year survival that was 82%, 79%, 78%, 82%, 78%, and 66% for patients with 0, 1, 2, 3, 4, and ≥5 points (P < 0.001). The LTRS remained an independent predictor after accounting for recipient sex, ethnicity, cause of liver disease, donor age, cold ischemia time, and waiting time. CONCLUSIONS The LTRS can stratify the short- and long-term outcomes of LT recipients at the time of their evaluations irrespective of their gender, ethnicity, and primary cause of liver disease.
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Bischoff SC, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, Plauth M. ESPEN practical guideline: Clinical nutrition in liver disease. Clin Nutr 2020; 39:3533-3562. [PMID: 33213977 DOI: 10.1016/j.clnu.2020.09.001] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Practical guideline is based on the current scientific ESPEN guideline on Clinical Nutrition in Liver Disease. METHODS It has been shortened and transformed into flow charts for easier use in clinical practice. The guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with chronic liver disease. RESULTS A total of 103 statements and recommendations are presented with short commentaries for the nutritional and metabolic management of patients with (i) acute liver failure, (ii) alcoholic steatohepatitis, (iii) non-alcoholic fatty liver disease, (iv) liver cirrhosis, and (v) liver surgery/transplantation. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in liver patients and on liver complications associated with medical nutrition. CONCLUSION This practical guideline gives guidance to health care providers involved in the management of liver disease to offer optimal nutritional care.
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Affiliation(s)
- Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany.
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Tatjana Schütz
- IFB Adiposity Diseases, Leipzig University Medical Centre, Leipzig, Germany
| | - Mathias Plauth
- Department of Internal Medicine, Municipal Hospital of Dessau, Dessau, Germany
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Prediction of Perioperative Mortality of Cadaveric Liver Transplant Recipients During Their Evaluations. Transplantation 2020; 103:e297-e307. [PMID: 31283673 PMCID: PMC6756253 DOI: 10.1097/tp.0000000000002810] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Supplemental Digital Content is available in the text. There are no instruments that can identify patients at an increased risk of poor outcomes after liver transplantation (LT) based only on their preoperative characteristics. The primary aim of this study was to develop such a scoring system. Secondary outcomes were to assess the discriminative performance of the predictive model for 90-day mortality, 1-year mortality, and 5-year patient survival.
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Puerta A, Núñez J, Vilar JA, Hervás PL, Nuño J. Cystic Duct Bile Leak in Graft: An Unexpected Origin for Choleperitoneum After Liver Transplant. EXP CLIN TRANSPLANT 2019; 18:638-640. [PMID: 31580232 DOI: 10.6002/ect.2019.0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
From the beginning of liver transplant implementation, biliary anastomosis has been considered its weakness. An anastomotic bile leak is the most frequent cause of bile in the peritoneum (choleperitoneum) after liver transplant but not the only one. Here, we report a 58-year-old man with hepatitis C virus-related cirrhosis who had orthotopic liver transplant due to presence of hepatocellular carcinoma.During the immediate postoperative period, bile leakwas diagnosed on trans-Kehr cholangiography. Contrast extravasation was observed on the graft's cystic duct, and no contrast flow into the native biliary tract was demonstrated. Surgical intervention was required after endoscopic management failure. Bile leak through the cystic duct was repaired, and a Rouxen-Y bilioenteric diversion was performed. Biliary complications can significantly increase morbidity and mortality after liver transplant. Anastomotic bile leaks are the most frequent; however, other locations must not be dismissed as possible origins of leak. It is mandatory to consider underlying hepatic artery complications as thrombosis or stenosis. Treatment will depend on the leak origin, which are most times accessible to endoscopic retrograde cholangiopancreatography. However, other locations and the different treatment options must also be considered. It is also necessary not to forget the influence of bile leaks on biliary stenosis development in the long term and its contribution to increased patient morbidity and mortality.
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Affiliation(s)
- Ana Puerta
- >From the Division of Hepatobiliary Surgery and Liver Transplant, Department of Surgery, Ramón y Cajal University Hospital, Madrid, Spain
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7
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Leon-Justel A, Alvarez-Rios AI, Noval-Padillo JA, Gomez-Bravo MA, Porras M, Gomez-Sosa L, Lopez-Romero JL, Guerrero JM. Point-of-care haemostasis monitoring during liver transplantation is cost effective. Clin Chem Lab Med 2019; 57:883-890. [PMID: 30530897 DOI: 10.1515/cclm-2018-0889] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/26/2018] [Indexed: 12/12/2022]
Abstract
Background Optimal haemostasis management in orthotropic liver transplant (OLT) could reduce blood loss and transfusion volume, improve patient outcomes and reduce cost. Methods We performed a study including 336 OLTs to evaluate the clinical and cost effectiveness of a new point-of-care (POC)-based haemostatic management approach in OLT patients. Results In terms of health benefit we found that the new approach showed a significant reduction in transfusion requirements (red blood cell transfusion units were reduced from 5.3±4.6 to 2.8±2.9 [p<0.001], free frozen plasma from 3.1±3.3 to 0.4±1.0 [p<0.001] and platelets from 2.9±3.9 to 0.4±0.9 [p<0.001], transfusion avoidance, 9.7% vs. 29.1% [p<0.001] and massive transfusion, 14.5% vs. 3.8% [p=0.001]); we also found a significant improvement in patient outcomes, such, reoperation for bleeding or acute-kidney-failure (8.3% vs. 2.4%, p=0.015; 33.6% vs. 5.4%, p<0.001), with a significant reduction in the length of the hospital total stay (40.6±13.8 days vs. 38.2±14.4 days, p=0.001). The lowest cost incurred was observed with the new approach (€73,038.80 vs. €158,912.90) with significant patient saving associated to transfusion avoidance (€1278.36), ICU-stay (€3037.26), total-stay (€3800.76) and reoperation for bleeding (€80,899.64). Conclusions POC haemostatic monitoring during OLT is cost effective.
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Affiliation(s)
| | - Ana I Alvarez-Rios
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, Seville, Spain.,Instituto de Biomedicina de Sevilla, IBIS (Universidad de Sevilla, HUVR, Junta de Andalucía, CSIC), Seville, Spain
| | - Jose A Noval-Padillo
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, Seville, Spain.,Instituto de Biomedicina de Sevilla, IBIS (Universidad de Sevilla, HUVR, Junta de Andalucía, CSIC), Seville, Spain
| | - Miguel A Gomez-Bravo
- Department of Hepatobiliary Surgery, Virgen del Rocío University Hospital, Seville, Spain
| | - Manuel Porras
- Department of Intensive Care Medicine, Virgen del Rocío University Hospital, Seville, Spain
| | - Laura Gomez-Sosa
- Department of Anaesthesiology, Virgen del Rocío University Hospital, Seville, Spain
| | - Juan L Lopez-Romero
- Department of Anaesthesiology, Virgen del Rocío University Hospital, Seville, Spain
| | - Juan M Guerrero
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, Seville, Spain.,Instituto de Biomedicina de Sevilla, IBIS (Universidad de Sevilla, HUVR, Junta de Andalucía, CSIC), Seville, Spain
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Plauth M, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, Bischoff SC. ESPEN guideline on clinical nutrition in liver disease. Clin Nutr 2019; 38:485-521. [PMID: 30712783 DOI: 10.1016/j.clnu.2018.12.022] [Citation(s) in RCA: 335] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 02/06/2023]
Abstract
This update of evidence-based guidelines (GL) aims to translate current evidence and expert opinion into recommendations for multidisciplinary teams responsible for the optimal nutritional and metabolic management of adult patients with liver disease. The GL was commissioned and financially supported by ESPEN. Members of the guideline group were selected by ESPEN. We searched for meta-analyses, systematic reviews and single clinical trials based on clinical questions according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing the SIGN method. A total of 85 recommendations were made for the nutritional and metabolic management of patients with acute liver failure, severe alcoholic steatohepatitis, non-alcoholic fatty liver disease, liver cirrhosis, liver surgery and transplantation as well as nutrition associated liver injury distinct from fatty liver disease. The recommendations are preceded by statements covering current knowledge of the underlying pathophysiology and pathobiochemistry as well as pertinent methods for the assessment of nutritional status and body composition.
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Affiliation(s)
- Mathias Plauth
- Department of Internal Medicine, Municipal Hospital of Dessau, Dessau, Germany.
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Tatjana Schütz
- IFB Adiposity Diseases, Leipzig University Medical Centre, Leipzig, Germany
| | - Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany
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9
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Gil E, Kim JM, Jeon K, Park H, Kang D, Cho J, Suh GY, Park J. Recipient Age and Mortality After Liver Transplantation: A Population-based Cohort Study. Transplantation 2018; 102:2025-2032. [PMID: 30153223 PMCID: PMC6257104 DOI: 10.1097/tp.0000000000002246] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 03/17/2018] [Accepted: 03/30/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND The feasibility of liver transplantation (LT) in elderly recipients remains a topic of debate. METHODS This cohort study evaluated the impact of recipient's age on LT outcome between January 2007 and May 2016 covered by the Korean National Health Insurance system (n = 9415). Multilevel regression models were used to determine the impact of recipient's age on in-hospital and long-term mortality after LT. RESULTS All patients had a first LT, with 2473 transplanted with liver from deceased donors (DD) and 6942 from living donors. The mean age was 52.2 ± 9.0 years. Most LT were performed on patients in their 50s (n = 4290, 45.6%) and 0.9% (n = 84) of the LT was performed on patients older 70 years. The overall in-hospital mortality was 6.3%, and the 3-year mortality was 11.3%. The in-hospital mortality included, 13.5% associated with DDLT and 3.7% involved living donor LT. When compared with that for patients aged 51 to 55 years, the risk of death among recipients older than 70 years was about fourfold higher after adjusting for baseline liver disease (odds ratio, 4.1; 95% confidence interval, 2.21-7.58), and was nearly threefold higher after adjusting for baseline liver disease and perioperative complications (odds ratio, 2.92; 95% confidence interval, 1.37-6.24). Also, the cost of LT increased significantly with age. CONCLUSIONS The data show that age remains an important risk factor for LT, suggesting that LT should be considered with caution in elderly recipients.
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Affiliation(s)
- Eunmi Gil
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Pulmonology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyejeong Park
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
- Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Juhee Cho
- Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Pulmonology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Jinkyeong Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Lee DH, Lee HW, Ahn YJ, Kim H, Yi NJ, Lee KW, Suh KS. Initiating Liver Transplantation at a Public Hospital in Korea. KOREAN JOURNAL OF TRANSPLANTATION 2017. [DOI: 10.4285/jkstn.2017.31.4.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Doo-ho Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Young Joon Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeyoung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Yunhua T, Weiqiang J, Maogen C, Sai Y, Zhiheng Z, Dongping W, Zhiyong G, Xiaoshun H. The combination of indocyanine green clearance test and model for end-stage liver disease score predicts early graft outcome after liver transplantation. J Clin Monit Comput 2017; 32:471-479. [PMID: 28831767 DOI: 10.1007/s10877-017-0051-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 07/27/2017] [Indexed: 12/13/2022]
Abstract
Early allograft dysfunction (EAD) and early postoperative complications are two important clinical endpoints when evaluating clinical outcomes of liver transplantation (LT). We developed and validated two ICGR15-MELD models in 87 liver transplant recipients for predicting EAD and early postoperative complications after LT by incorporating the quantitative liver function tests (ICGR15) into the MELD score. Eighty seven consecutive patients who underwent LT were collected and divided into a training cohort (n = 61) and an internal validation cohort (n = 26). For predicting EAD after LT, the area under curve (AUC) for ICGR15-MELD score was 0.876, with a sensitivity of 92.0% and a specificity of 75.0%, which is better than MELD score or ICGR15 alone. The recipients with a ICGR15-MELD score ≥0.243 have a higher incidence of EAD than those with a ICGR15-MELD score <0.243 (P <0.001). For predicting early postoperative complications, the AUC of ICGR15-MELD score was 0.832, with a sensitivity of 90.9% and a specificity of 71.0%. Those recipients with an ICGR15-MELD score ≥0.098 have a higher incidence of early postoperative complications than those with an ICGR15-MELD score <0.098 (P < 0.001). Finally, application of the two ICGR15-MELD models in the validation cohort still gave good accuracy (AUC, 0.835 and 0.826, respectively) in predicting EAD and early postoperative complications after LT. The combination of quantitative liver function tests (ICGR15) and the preoperative MELD score is a reliable and effective predictor of EAD and early postoperative complications after LT, which is better than MELD score or ICGR15 alone.
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Affiliation(s)
- Tang Yunhua
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, NO. 58 Zhongshan Er Road, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Ju Weiqiang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, NO. 58 Zhongshan Er Road, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Chen Maogen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, NO. 58 Zhongshan Er Road, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Yang Sai
- Guangdong Provincial Center for Skin Diseases and STI Control and Prevention, Guangzhou, China
| | - Zhang Zhiheng
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, NO. 58 Zhongshan Er Road, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Wang Dongping
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, NO. 58 Zhongshan Er Road, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Guo Zhiyong
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, NO. 58 Zhongshan Er Road, Guangzhou, 510080, China.
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China.
| | - He Xiaoshun
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, NO. 58 Zhongshan Er Road, Guangzhou, 510080, China.
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China.
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Rojas-Loureiro G, Servín-Caamaño A, Pérez-Reyes E, Servín-Abad L, Higuera-de la Tijera F. Malnutrition negatively impacts the quality of life of patients with cirrhosis: An observational study. World J Hepatol 2017; 9:263-269. [PMID: 28261383 PMCID: PMC5316846 DOI: 10.4254/wjh.v9.i5.263] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 09/12/2016] [Accepted: 12/09/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To verify how malnutrition is related to health-related quality of life (HRQL) impairment in patients with cirrhosis.
METHODS Data was retrospectively abstracted from medical records and obtained by direct interview. We included patients with cirrhosis from any etiology, evaluated at the Liver Clinic from Gastroenterology Department in a tertiary healthcare center, from June 2014 to June 2016. Child-Pugh score, data about complications, and demographic, clinical and anthropometric characteristics of patients were obtained. Nutritional status was evaluated by the Subjective Global Assessment (SGA). HRQL was evaluated through the Chronic Liver Disease Questionnaire. Patients were requested to assess their global HRQL with the following code: 0 = impairment of HRQL, when it was compared with other healthy subjects; 1 = good HRQL, if it was similar to the quality of life of other healthy subjects. To compare the primary outcome between malnourished and well-nourished groups, the χ2 test, Fisher’s exact test or Student’s t-test were used, based on the variable type. Associations between predictor variables and deterioration of HRQL were determined by calculating the hazard ratio and 95% confidence interval using Cox proportional hazards regression.
RESULTS A total of 127 patients with cirrhosis were included, and the mean age was 54.1 ± 12.3 years-old. According to Child-Pugh scoring, 25 (19.7%) were classified as A (compensated), 76 (59.8%) as B, and 26 (20.5%) as C (B/C = decompensated). According to SGA, 58 (45.7%) patients were classified as well-nourished. Sixty-nine patients identified HRQL as good, and 76 patients (59.8%) perceived impairment of their HRQL. Multivariate analysis to determine associations between predictor variables and self-perception of an impairment of HRQL found strong association with malnutrition (P < 0.0001). The most important impaired characteristics in malnourished patients were: Presence of body pain, dyspnea on exertion with daily activities, decreased appetite, generalized weakness, trouble lifting or carrying heavy objects, and decreased level of energy (P < 0.0001).
CONCLUSION Malnutrition is a key factor related to impairment of HRQL in patients with cirrhosis.
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de Camargo Aranzana EM, Coppini AZ, Ribeiro MA, Massarollo PCB, Szutan LA, Ferreira FG. Model for End-Stage Liver Disease, Model for Liver Transplantation Survival and Donor Risk Index as predictive models of survival after liver transplantation in 1,006 patients. Clinics (Sao Paulo) 2015; 70:413-8. [PMID: 26106959 PMCID: PMC4462569 DOI: 10.6061/clinics/2015(06)05] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 03/19/2015] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Liver transplantation has not increased with the number of patients requiring this treatment, increasing deaths among those on the waiting list. Models predicting post-transplantation survival, including the Model for Liver Transplantation Survival and the Donor Risk Index, have been created. Our aim was to compare the performance of the Model for End-Stage Liver Disease, the Model for Liver Transplantation Survival and the Donor Risk Index as prognostic models for survival after liver transplantation. METHOD We retrospectively analyzed the data from 1,270 patients who received a liver transplant from a deceased donor in the state of São Paulo, Brazil, between July 2006 and July 2009. All data obtained from the Health Department of the State of São Paulo at the 15 registered transplant centers were analyzed. Patients younger than 13 years of age or with acute liver failure were excluded. RESULTS The majority of the recipients had Child-Pugh class B or C cirrhosis (63.5%). Among the 1,006 patients included, 274 (27%) died. Univariate survival analysis using a Cox proportional hazards model showed hazard ratios of 1.02 and 1.43 for the Model for End-Stage Liver Disease and the Model for Liver Transplantation Survival, respectively (p<0.001). The areas under the ROC curve for the Donor Risk Index were always less than 0.5, whereas those for the Model for End-Stage Liver Disease and the Model for Liver Transplantation Survival were significantly greater than 0.5 (p<0.001). The cutoff values for the Model for End-Stage Liver Disease (≥29.5; sensitivity: 39.1%; specificity: 75.4%) and the Model for Liver Transplantation Survival (≥1.9; sensitivity 63.9%, specificity 54.5%), which were calculated using data available before liver transplantation, were good predictors of survival after liver transplantation (p<0.001). CONCLUSIONS The Model for Liver Transplantation Survival displayed similar death prediction performance to that of the Model for End-Stage Liver Disease. A simpler model involving fewer variables, such as the Model for End-Stage Liver Disease, is preferred over a complex model involving more variables, such as the Model for Liver Transplantation Survival. The Donor Risk Index had no significance in post-transplantation survival in our patients.
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Affiliation(s)
- Elisa Maria de Camargo Aranzana
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Surgery Department, Liver and Portal Hypertension Group, São Paulo/SP,Brazil
- Elisa Maria de Camargo AranzanaCorresponding author: E-mail:
| | | | - Maurício Alves Ribeiro
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Surgery Department, Liver and Portal Hypertension Group, São Paulo/SP,Brazil
| | | | - Luiz Arnaldo Szutan
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Surgery Department, Liver and Portal Hypertension Group, São Paulo/SP,Brazil
| | - Fabio Gonçalves Ferreira
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Surgery Department, Liver and Portal Hypertension Group, São Paulo/SP,Brazil
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Cimen S, Guler S, Ayloo S, Molinari M. Implications of Hyponatremia in Liver Transplantation. J Clin Med 2014; 4:66-74. [PMID: 26237018 PMCID: PMC4470239 DOI: 10.3390/jcm4010066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 12/05/2014] [Indexed: 12/28/2022] Open
Abstract
Although there are a limited number of quality studies, appropriate peri-operative management of serum electrolytes seems to reduce adverse outcomes in liver transplantation. Hyponatremia is defined as the presence of serum concentration of sodium equal ≤130 mmol/L and it is detected in approximately 20% of patients with end stage liver disease waiting for a liver transplant (LT). This paper will focus on the pathogenesis of dilutional hyponatremia and its significance in terms of both candidacy for LT and post-operative outcomes.
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Affiliation(s)
- Sertac Cimen
- Department of Surgery and Community Health, Dalhousie University, 1276 South Park Street, Halifax, B3H 2Y9, NS, Canada.
| | - Sanem Guler
- Department of Surgery and Community Health, Dalhousie University, 1276 South Park Street, Halifax, B3H 2Y9, NS, Canada.
| | - Subhashini Ayloo
- Department of Surgery and Community Health, Dalhousie University, 1276 South Park Street, Halifax, B3H 2Y9, NS, Canada.
| | - Michele Molinari
- Department of Surgery and Community Health, Dalhousie University, 1276 South Park Street, Halifax, B3H 2Y9, NS, Canada.
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Dopazo C, Bilbao I, Castells LL, Sapisochin G, Moreiras C, Campos-Varela I, Echeverri J, Caralt M, Lázaro JL, Charco R. Analysis of adult 20-year survivors after liver transplantation. Hepatol Int 2014; 9:461-70. [PMID: 25788182 PMCID: PMC4473278 DOI: 10.1007/s12072-014-9577-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 08/21/2014] [Indexed: 02/07/2023]
Abstract
Background Liver transplantation (LT) is the treatment of choice for chronic and acute liver failure; however, the status of long-term survivors and allograft function is not well known. Aim To evaluate the clinical outcome and allograft function of survivors 20 years post-LT, cause of death during the same period and risk factors of mortality. Methods A retrospective study was conducted from prospective, longitudinal data collected at a single center of adult LT recipients surviving 20 years. A comparative sub-analysis was made with patients who were not alive 20 years post-transplantation to identify the causes of death and risk factors of mortality. Results Between 1988 and 1994, 132 patients received 151 deceased-donors LT and 28 (21 %) survived more than 20 years. Regarding liver function in this group, medians of AST, ALT and total bilirubin at 20 years post-LT were 33 IU/L (13–135 IU/L), 27 (11–152 IU/L) and 0.6 mg/dL (0.3–1.1 mg/dL). Renal dysfunction was observed in 40 % of patients and median eGFR among 20-year survivors was 64 mL/min/1.73 m2 (6–144 mL/min/1.73 m2). Sixty-one percent of 20-year survivors had arterial hypertension, 43 % dyslipidemia, 25 % de novo tumors and 21 % diabetes mellitus. Infections were the main cause of death during the 1st year post-transplant (32 %) and between the 1st and 5th year post-transplant (25 %). After 5th year from transplant, hepatitis C recurrence (22 %) became the first cause of death. Factors having an impact on long-term patient survival were HCC indication (p = 0.049), pre-transplant renal dysfunction (p = 0.043) and long warm ischemia time (p = 0.016); furthermore, post-transplant factors were diabetes mellitus (p = 0.001) and liver dysfunction (p = 0.05) at 1 year. Conclusion Our results showed the effect of immunosuppression used during decades on long-term outcome in our LT patients in terms of morbidity (arterial hypertension, diabetes mellitus, dyslipidemia and renal dysfunction) and mortality (infections and hepatitis C recurrence).
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Affiliation(s)
- C Dopazo
- Department of HBP Surgery and Transplants, Hospital Universitario Vall d´Hebron, Universidad Autónoma de Barcelona, Paseo Vall d´Hebron 119-129, 08035, Barcelona, Spain,
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16
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Schoening WN, Buescher N, Rademacher S, Andreou A, Kuehn S, Neuhaus R, Guckelberger O, Puhl G, Seehofer D, Neuhaus P. Twenty-year longitudinal follow-up after orthotopic liver transplantation: a single-center experience of 313 consecutive cases. Am J Transplant 2013; 13:2384-94. [PMID: 23915357 DOI: 10.1111/ajt.12384] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 05/13/2013] [Accepted: 06/12/2013] [Indexed: 02/06/2023]
Abstract
With excellent short-term survival in liver transplantation (LT), we now focus on long-term outcome and report the first European single-center 20-year survival data. Three hundred thirty-seven LT were performed in 313 patients (09/88-12/92). Impact on long-term outcome was studied and a comparison to life expectancy of matched normal population was performed. A detailed analysis of 20-years follow-up concerning overweight (HBMI), hypertension (HTN), diabetes (HGL), hyperlipidemia (HLIP) and moderately or severely impaired renal function (MIRF, SIRF) is presented. Patient and graft survival at 1, 10, 20 years were 88.4%, 72.7%, 52.5% and 83.7%, 64.7% and 46.6%, respectively. Excluding 1-year mortality, survival in the elderly LT recipients was similar to normal population. Primary indication (p < 0.001), age (p < 0.001), gender (p = 0.017), impaired renal function at 6 months (p < 0.001) and retransplantation (p = 0.034) had significant impact on patient survival. Recurrent disease (21.3%), infection (20.6%) and de novo malignancy (19.9%) were the most common causes of death. Prevalence of HTN (57.3-85.2%, p < 0.001), MIRF (41.8-55.2%, p = 0.01) and HBMI (33.2-45%, p = 0.014) increased throughout follow-up, while prevalence of HLIP (78.0-47.6%, p < 0.001) declined. LT has conquered many barriers to achieve these outstanding long-term results. However, much work is needed to combat recurrent disease and side effects of immunosuppression (IS).
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Vos JJ, Scheeren TWL, Lukes DJ, de Boer MT, Hendriks HGD, Wietasch JKG. Intraoperative ICG plasma disappearance rate helps to predict absence of early postoperative complications after orthotopic liver transplantation. J Clin Monit Comput 2013; 27:591-8. [DOI: 10.1007/s10877-013-9474-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 05/06/2013] [Indexed: 01/27/2023]
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Abstract
Post-transplant, nonalcoholic hepatic steatosis and steatohepatitis are increasingly recognized as a complication of liver transplantation, and the progression of the latter through fibrosis to cirrhosis has been clearly shown. Non-alcoholic steatohepatitis (NASH) is independently associated with an increased risk of death from cardiovascular and liver diseases. While optimal therapy is not yet available in the post-liver transplant setting, knowledge gained in the therapy of NASH in the non-transplant setting can be used to design therapeutic interventions. In addition, early recognition with protocol liver biopsies and an effective preventive strategy by modifying known risk factors implicated in the recurrence of NASH would be the most effective way to curtail the progression of NASH before an effective treatment can be found. Additional rigorous research aimed at elucidating the pathogenesis, natural history, and selection of immunosuppressants for NASH is clearly warranted.
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Affiliation(s)
- Sanjaya Kumar Satapathy
- Department of Surgery, Methodist University Hospital Transplant Institute, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 340, Memphis, TN, 38104, USA.
| | - Satheesh Nair
- Department of Surgery, Methodist University Hospital Transplant Institute, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 340, Memphis, TN, 38104, USA
| | - Jason M Vanatta
- Department of Surgery, Methodist University Hospital Transplant Institute, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 340, Memphis, TN, 38104, USA
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Periyalwar P, Dasarathy S. Malnutrition in cirrhosis: contribution and consequences of sarcopenia on metabolic and clinical responses. Clin Liver Dis 2012; 16:95-131. [PMID: 22321468 PMCID: PMC4383161 DOI: 10.1016/j.cld.2011.12.009] [Citation(s) in RCA: 175] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Malnutrition is the most common, reversible complication of cirrhosis that adversely affects survival, response to other complications, and quality of life. Sarcopenia, or loss of skeletal muscle mass, and loss of adipose tissue and altered substrate use as a source of energy are the 2 major components of malnutrition in cirrhosis. Current therapies include high protein supplementation especially as a late evening snack. Exercise protocols have the potential of aggravating hyperammonemia and portal hypertension. Recent advances in understanding the molecular regulation of muscle mass has helped identify potential novel therapeutic targets including myostatin antagonists, and mTOR resistance.
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Affiliation(s)
- Pranav Periyalwar
- Department of Gastroenterology, Metrohealth Medical Center, 2500 Metrohealth Drive, Cleveland, OH 44109, USA
- Department of Gastroenterology and Hepatology, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, NE4-208, Cleveland, OH 44195, USA
| | - Srinivasan Dasarathy
- Department of Gastroenterology and Hepatology, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, NE4-208, Cleveland, OH 44195, USA
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, NE4-208, Cleveland, OH 44195, USA
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20
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Prentis JM, Manas DMD, Trenell MI, Hudson M, Jones DJ, Snowden CP. Submaximal cardiopulmonary exercise testing predicts 90-day survival after liver transplantation. Liver Transpl 2012; 18:152-9. [PMID: 21898768 DOI: 10.1002/lt.22426] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Liver transplantation has a significant early postoperative mortality rate. An accurate preoperative assessment is essential for minimizing mortality and optimizing limited donor organ resources. This study assessed the feasibility of preoperative submaximal cardiopulmonary exercise testing (CPET) for determining the cardiopulmonary reserve in patients being assessed for liver transplantation and its potential for predicting 90-day posttransplant survival. One hundred eighty-two patients underwent CPET as part of their preoperative assessment for elective liver transplantation. The 90-day mortality rate, critical care length of stay, and hospital length of stay were determined during the prospective posttransplant follow-up. One hundred sixty-five of the 182 patients (91%) successfully completed CPET; this was defined as the ability to determine a submaximal exercise parameter: the anaerobic threshold (AT). Sixty of the 182 patients (33%) underwent liver transplantation, and the mortality rate was 10.0% (6/60). The mean AT value was significantly higher for survivors versus nonsurvivors (12.0 ± 2.4 versus 8.4 ± 1.3 mL/minute/kg, P < 0.001). Logistic regression revealed that AT, donor age, blood transfusions, and fresh frozen plasma transfusions were significant univariate predictors of outcomes. In a multivariate analysis, only AT was retained as a significant predictor of mortality. A receiver operating characteristic curve analysis demonstrated sensitivity and specificity of 90.7% and 83.3%, respectively, with good model accuracy (area under the receiver operating characteristic curve = 0.92, 95% confidence interval = 0.82-0.97, P = 0.001). The optimal AT level for survival was defined to be >9.0 mL/minute/kg. The predictive value was improved when the ideal weight was substituted for the actual body weight of a patient with refractory ascites, even after a correction for the donor's age. In conclusion, the preoperative cardiorespiratory reserve (as defined by CPET) is a sensitive and specific predictor of early survival after liver transplantation. The predictive value of CPET requires further evaluation.
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Affiliation(s)
- James M Prentis
- Department of Perioperative and Critical Care Medicine, Freeman Hospital, Newcastle upon Tyne, UK.
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[Causes of early mortality after liver transplantation: a twenty-years single centre experience]. ACTA ACUST UNITED AC 2011; 30:899-904. [PMID: 22035834 DOI: 10.1016/j.annfar.2011.06.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 06/21/2011] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To define the causes of mortality of patients who died within the first three months after a liver transplantation. TYPE OF STUDY Retrospective, observational, and single centre study. PATIENTS AND METHODS Between March 1989 and July 2010, all patients who died within three months after a liver transplantation were included. Demographic characteristics, preoperative and peroperative data, donor characteristics, postoperative complications and causes of mortality were collected. RESULTS Among the 788 performed liver transplantations, 76 patients died in intensive care unit (11%). The main indications of liver transplantation were alcoholic cirrhosis (30%), hepatitis C (28%), hepatocarcinoma (15%), primitive or secondary biliary cirrhosis (10%). Fifty percent of the patients were categorized as Child C. The main causes of death were non-function or dysfunction with retransplantation contra-indication graft (18%), sepsis (18%), neurological complications (12%), hemorrhagic shock (13%), (9%), multiorgan failures (5%), cardiac complications (6%). CONCLUSION In this study, the main causes of mortality were infectious, neurological and hemorrhagic. These results emphasize the necessity for better control of sepsis, haemorrhage and immunosupressors.
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Pre-operative risk factors predict post-operative respiratory failure after liver transplantation. PLoS One 2011; 6:e22689. [PMID: 21829646 PMCID: PMC3148242 DOI: 10.1371/journal.pone.0022689] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 06/28/2011] [Indexed: 12/27/2022] Open
Abstract
Objective Post-operative pulmonary complications significantly affect patient survival rates, but there is still no conclusive evidence regarding the effect of post-operative respiratory failure after liver transplantation on patient prognosis. This study aimed to predict the risk factors for post-operative respiratory failure (PRF) after liver transplantation and the impact on short-term survival rates. Design The retrospective observational cohort study was conducted in a twelve-bed adult surgical intensive care unit in northern Taiwan. The medical records of 147 liver transplant patients were reviewed from September 2002 to July 2007. Sixty-two experienced post-operative respiratory failure while the remaining 85 patients did not. Measurements and Main Results Gender, age, etiology, disease history, pre-operative ventilator use, molecular adsorbent re-circulating system (MARS) use, source of organ transplantation, model for end-stage liver disease score (MELD) and Child-Turcotte-Pugh score calculated immediately before surgery were assessed for the two groups. The length of the intensive care unit stay, admission duration, and mortality within 30 days, 3 months, and 1 year were also evaluated. Using a logistic regression model, post-operative respiratory failure correlated with diabetes mellitus prior to liver transplantation, pre-operative impaired renal function, pre-operative ventilator use, pre-operative MARS use and deceased donor source of organ transplantation (p<0.05). Once liver transplant patients developed PRF, their length of ICU stay and admission duration were prolonged, significantly increasing their mortality and morbidity (p<0.001). Conclusions The predictive pre-operative risk factors significantly influenced the occurrence of post-operative respiratory failure after liver transplantation.
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Schneider L, Spiegel M, Latanowicz S, Weigand MA, Schmidt J, Werner J, Stremmel W, Eisenbach C. Noninvasive indocyanine green plasma disappearance rate predicts early complications, graft failure or death after liver transplantation. Hepatobiliary Pancreat Dis Int 2011; 10:362-8. [PMID: 21813383 DOI: 10.1016/s1499-3872(11)60061-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Early detection of graft malfunction or postoperative complications is essential to save patients and organs after orthotopic liver transplantation (OLT). Predictive tests for graft dysfunction are needed to enable earlier implementation of organ-saving interventions following transplantation. This study was undertaken to assess the value of indocyanine green plasma disappearance rates (ICG-PDRs) for predicting postoperative complications, graft dysfunction, and patient survival following OLT. METHODS Eighty-six patients undergoing OLT were included in this single-centre trial. ICG-PDR was assessed daily for the first 7 days following OLT. Endpoints were graft loss or death within 30 days and postoperative complications, graft loss, or death within 30 days. RESULTS Postoperative complications of 31 patients included deaths (12 patients) or graft losses. ICG-PDR was significantly different in patients whose endpoints were graft loss or death beginning from day 3 and in those whose endpoints were graft-loss, death, or postoperative complications beginning from day 4 after OLT. For day 7 measurements, receiver operating characteristic curve analysis revealed an ICG-PDR cut-off for predicting death or graft loss of 9.6% per min (a sensitivity of 75.0%, a specificity of 72.6%, positive predictive value 0.35, negative predictive value 0.94). For prediction of graft loss, death, or postoperative complications, the ICG-PDR cut-off was 12.3% per min (a sensitivity of 68.9%, a specificity of 66.7%, positive predictive value 0.57, negative predictive value 0.77). CONCLUSIONS ICG-PDR measurements on postoperative day 7 are predictive of early patient outcomes following OLT. The added value over that of routinely determined laboratory parameters is low.
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Affiliation(s)
- Lutz Schneider
- Department of General Surgery, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, Germany
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Schneider L, Latanowicz S, Spiegel M, Stremmel W, Büchler M, Schmidt J, Eisenbach C. Prospective Validation of a Simple Laboratory Score to Predict Outcome After Orthotopic Liver Transplantation. Transplant Proc 2011; 43:1747-50. [DOI: 10.1016/j.transproceed.2011.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 12/23/2010] [Accepted: 02/07/2011] [Indexed: 02/06/2023]
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Bispo M, Marcelino P, Marques HP, Martins A, Perdigoto R, Aguiar MJ, Mourão L, Barroso E. Domino versus deceased donor liver transplantation: association with early graft function and perioperative bleeding. Liver Transpl 2011; 17:270-8. [PMID: 21384509 DOI: 10.1002/lt.22210] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This study sought to evaluate the potential impact of domino liver transplantation (DLT) on initial graft function and early postoperative outcome in patients with cirrhosis in a Portuguese liver transplantation center. A retrospective comparative analysis was performed between 77 domino recipients (from familial amyloidotic polyneuropathy donors) and 91 deceased donor recipients, all submitted to primary elective whole liver transplantation, using the piggyback technique, in a 42-month period. Outcome parameters included graft dysfunction (defined as either primary nonfunction or initial poor function, according to the Ploeg-Maring criteria) and Clavien II-IV complications in the first postoperative week. Domino and deceased donor recipients had similar preoperative severity indices (Child-Pugh classification and Model for End-Stage Liver Disease score) and immediate postoperative severity scores (APACHE II [Acute Physiology and Chronic Health Evaluation II] and SAPS II [Simplified Acute Physiology Score II]). In DLT, donors were younger, cold ischemia time was shorter, and intraoperative transfusion requirements of packed red blood cells and fresh-frozen plasma were significantly lower. Graft dysfunction incidence was 3.4-fold lower in DLT: 5.2% (only 4 cases of initial poor function) versus 18.0% (1 primary nonfunction and 15 cases of initial poor function), P = 0.010. Postoperative bleeding was the most frequent early Clavien II-IV complication (n = 29, 17.3%), with an incidence 2.2-fold lower in domino recipients. A statistically significant difference was not found in the other analyzed Clavien II-IV complications, intensive care unit stay, mechanical ventilation time, intensive care unit mortality, and 1-year survival rate. In conclusion, in this study the younger donors and shorter ischemic time associated with DLT may provide a protective role in regards to graft dysfunction and perioperative bleeding, which are 2 important determinants of early morbidity after liver transplantation.
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Affiliation(s)
- Miguel Bispo
- Intensive Care Unit, Curry Cabral Hospital, Lisbon, Portugal.
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Mortality after percutaneous endoscopic gastrostomy in patients with cirrhosis: a case series. Gastrointest Endosc 2010; 72:1072-5. [PMID: 20855067 DOI: 10.1016/j.gie.2010.06.043] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 06/14/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) tube placement can improve the nutritional status and the ability of a patient with cirrhosis to recover from surgery such as orthotopic liver transplantation. However, cirrhosis has been considered a significant contraindication to PEG tube placement. OBJECTIVE Our aim in this study was to describe the mortality and complications in a series of cirrhotic patients who underwent PEG at our institution. DESIGN Retrospective, single-institution case series. PATIENTS This study involved 26 consecutive patients with cirrhosis who underwent PEG between 1995 and 2005. INTERVENTION PEG tube placement. MAIN OUTCOME MEASUREMENTS AND RESULTS The 30-day mortality of the series of patients was 10 of 26 (38.5%), whereas the 90-day mortality was 11 of 26 (42.3%). Nine of the 10 patients who died in the first 30 days had ascites at the time of PEG tube placement. Two patients died as a direct consequence of complications from the PEG procedure, whereas the other deaths were related to progression of liver disease or factors not directly related to the PEG. LIMITATIONS The patients in this case series had varying levels of illness and reasons for PEG tube placement such that a generalization of outcomes may not be possible. CONCLUSIONS The overall mortality of patients with cirrhosis who underwent PEG is high. Although there is an increased risk, PEG tube placement in cirrhotic patients without ascites may be less risky. The benefits of PEG tube placement in patients with cirrhosis should be weighed heavily against the risks.
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Spitzer AL, Lao OB, Dick AAS, Bakthavatsalam R, Halldorson JB, Yeh MM, Upton MP, Reyes JD, Perkins JD. The biopsied donor liver: incorporating macrosteatosis into high-risk donor assessment. Liver Transpl 2010; 16:874-84. [PMID: 20583086 DOI: 10.1002/lt.22085] [Citation(s) in RCA: 239] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
To expand the donor liver pool, ways are sought to better define the limits of marginally transplantable organs. The Donor Risk Index (DRI) lists 7 donor characteristics, together with cold ischemia time and location of the donor, as risk factors for graft failure. We hypothesized that donor hepatic steatosis is an additional independent risk factor. We analyzed the Scientific Registry of Transplant Recipients for all adult liver transplants performed from October 1, 2003, through February 6, 2008, with grafts from deceased donors to identify donor characteristics and procurement logistics parameters predictive of decreased graft survival. A proportional hazard model of donor variables, including percent steatosis from higher-risk donors, was created with graft survival as the primary outcome. Of 21,777 transplants, 5051 donors had percent macrovesicular steatosis recorded on donor liver biopsy. Compared to the 16,726 donors with no recorded liver biopsy, the donors with biopsied livers had a higher DRI, were older and more obese, and a higher percentage died from anoxia or stroke than from head trauma. The donors whose livers were biopsied became our study group. Factors most strongly associated with graft failure at 1 year after transplantation with livers from this high-risk donor group were donor age, donor liver macrovesicular steatosis, cold ischemia time, and donation after cardiac death status. In conclusion, in a high-risk donor group, macrovesicular steatosis is an independent risk factor for graft survival, along with other factors of the DRI including donor age, donor race, donation after cardiac death status, and cold ischemia time.
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Affiliation(s)
- Austin L Spitzer
- Kaiser Permanente, Oakland Medical Center, Department of Surgery, Oakland, CA, USA
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Gopal PB, Kapoor D, Raya R, Subrahmanyam M, Juneja D, Sukanya B. Critical care issues in adult liver transplantation. Indian J Crit Care Med 2010; 13:113-9. [PMID: 20040807 PMCID: PMC2823091 DOI: 10.4103/0972-5229.58535] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Over the last decade, liver transplantation has become an operational reality in our part of the world. As a result, clinicians working in an intensive care unit are more likely to be exposed to these patients in the immediate postoperative period, and thus, it is important that they have a working knowledge of the common complications, when they are likely to occur, and how to deal with them. The main focus of this review is to address the variety of critical care issues in liver transplant recipients and to impress upon the need to provide favorable circumstances for the new liver to start functioning and maintain the function of other organs to aid in this process.
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Affiliation(s)
- Palepu B Gopal
- Department of Anesthesia and Critical Care Medicine, Global Hospital, Lak di-ka-pul, Hyderabad - 560 004, India.
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Marudanayagam R, Shanmugam V, Sandhu B, Gunson BK, Mirza DF, Mayer D, Buckels J, Bramhall SR. Liver retransplantation in adults: a single-centre, 25-year experience. HPB (Oxford) 2010; 12:217-24. [PMID: 20590890 PMCID: PMC2889275 DOI: 10.1111/j.1477-2574.2010.00162.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Retransplantation is the only form of treatment for patients with irreversible graft failure. The aim of this study was to analyse a single centre's experience of the indications for and outcomes of retransplantation. METHODS A total of 196 patients who underwent liver retransplantation using 225 grafts, between January 1982 and July 2007, were included in the study. The following parameters were analysed: patient demographics; primary diagnosis; distribution of retransplantation over different time periods; indications for retransplantation; time interval to retransplantation, and overall patient and graft survival. RESULTS Of the 2437 primary orthotopic liver transplantations, 196 patients (8%) required a first regraft, 23 patients (1%) a second regraft and six patients (0.25%) a third regraft. Autoimmune hepatitis was the most common primary diagnosis for which retransplantation was required (12.7% of primary transplantations). The retransplantation rate declined from 12% at the beginning of our programme to 7.6% at the end of the study period. The most common indication for retransplantation was hepatic artery thrombosis (31.6%). Nearly two-thirds of the retransplantations were performed within 6 months of the primary transplantation. The 1-, 3-, 5- and 10-year patient survival rates following first retransplantation were 66%, 61%, 57% and 47%, respectively. Five-year survival after second retransplantation was 40%. None of the patients have yet survived 3 years after a third regraft. Donor age of < or =55 years and a MELD (Model for End-stage Liver Disease) score of < or =23 were associated with better outcome following retransplantation. CONCLUSIONS First retransplantation was associated with good longterm survival. There was no survival benefit following second and third retransplantations. A MELD score of < or =23 and donor age of < or =55 years correlated with better outcome following retransplantation.
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Affiliation(s)
- Ravi Marudanayagam
- Liver Unit, Queen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
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Badia-Tahull M, Llop-Talaveron J, Fort-Casamartina E, Farran-Teixidor L, Ramon-Torrel J, Jódar-Masanés R. Preoperative albumin as a predictor of outcome in gastrointestinal surgery. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.eclnm.2009.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Levesque E, Saliba F, Benhamida S, Ichaï P, Azoulay D, Adam R, Castaing D, Samuel D. Plasma disappearance rate of indocyanine green: a tool to evaluate early graft outcome after liver transplantation. Liver Transpl 2009; 15:1358-64. [PMID: 19790157 DOI: 10.1002/lt.21805] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Indocyanine green clearance (Cl-ICG) has been used to assess liver function and hepatic blood flow mainly before and after hepatic surgery. Cl-ICG (invasive method) has been reported to be a good marker of early graft function after liver transplantation (LT). The goal of this study was to determine if the indocyanine green plasma disappearance rate (PDR-ICG), measured by a noninvasive technique (LiMON, Impulse Medical System, Munich, Germany), is predictive of complications and graft outcome after LT. From September 2005 to June 2006, 72 LT recipients were included in the study. PDR-ICG was measured daily (from day 0 to day 5 after LT) with a digital sensor after patients were injected with 0.25 mg/kg indocyanine green. A PDR-ICG cutoff level of 12.85%/minute was predictive of the development of a serious postoperative complication. The sequential changes of PDR-ICG enabled us to differentiate 2 groups: (1) patients with early severe complications (hepatic artery thrombosis, primary graft nonfunction, or sepsis) who had a low value of PDR-ICG during the first 5 posttransplantation days (average, 8.8 +/- 4.5%/minute) and (2) patients who developed acute rejection and who had a progressive reduction of PDR-ICG between days 0 and 5 (from 25.5 +/- 4.8 to 10.3 +/- 2.5%/minute; P < 0.002). In conclusion, after LT, PDR-ICG (a noninvasive technique), measured regularly during the first 5 postoperative days, is a safe technique that can predict early postoperative complications.
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Affiliation(s)
- Eric Levesque
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
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Thuluvath PJ. Morbid obesity and gross malnutrition are both poor predictors of outcomes after liver transplantation: what can we do about it? Liver Transpl 2009; 15:838-41. [PMID: 19642129 DOI: 10.1002/lt.21824] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Brandão A, Fuchs SC, Gleisner AL, Marroni C, Zanotelli ML, Cantisani G. MELD and other predictors of survival after liver transplantation. Clin Transplant 2009; 23:220-7. [PMID: 19210688 DOI: 10.1111/j.1399-0012.2008.00943.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND This study examined how reliable is the pre-transplant model for end-stage liver disease (MELD) score in predicting post-transplantation survival and analyzed variables associated with patient survival. METHODS A cohort study was conducted. Receiver operating characteristic curve c-statistics were used to determine the ability of MELD score to predict mortality. The Kaplan-Meier (KM) method was used to analyze survival as a function of time regarding the MELD score and Child-Turcotte-Pugh (CTP) category. The Cox model was employed to assess the association between baseline risk factors and mortality. RESULTS Recipients and donors were mostly male, with a mean age of 51.6 and 38.5 yr, respectively (n = 436 transplants). The c-statistic values for three-month patient mortality were 0.60 and 0.61 for MELD score and CTP category, respectively. KM survival at three, six and 12 months were lower in those who had a MELD score > or =21 or were CTP category C. Multivariate analysis revealed that recipient age > or =65 yr, MELD > or = 21, CTP C category, bilirubin > or = 7 mg/dL, creatinine > or = 1.5 mg/dL, platelet transfusion, hepatocellular carcinoma, and non-white color donor skin were predictors of mortality. CONCLUSIONS Severe pre-transplant liver disease, age > or = 65, non-white skin donor, and hepatocellular carcinoma are associated with poor outcome.
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Affiliation(s)
- Ajacio Brandão
- Liver Transplantation Group, Complexo Hospitalar Santa Casa, Porto Alegre-RS, Brazil.
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34
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Lam VW, Poon RT. Role of branched-chain amino acids in management of cirrhosis and hepatocellular carcinoma. Hepatol Res 2008; 38 Suppl 1:S107-15. [PMID: 19125941 DOI: 10.1111/j.1872-034x.2008.00435.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Altered protein and energy metabolism is a hallmark of chronic liver disease, characterized by decreased plasma branched-chain amino acids (BCAA) and increased plasma aromatic amino acids (AAA). Overwhelming evidence has indicated that the incidence of complications of chronic liver disease increases with malnutrition. Hence nutritional management in patients with chronic liver disease must receive high priority. The use of BCAA supplementation has been a controversial subject. This review summarizes published results of BCAA supplementation as a nutritional therapy for patients with cirrhosis and hepatocellular carcinoma (HCC). On balance, it would be appropriate to conclude that BCAA are associated with decreased frequency of complications of cirrhosis and improved nutritional status when prescribed as a maintenance therapy for patients with cirrhosis. More studies are, however, required to identify those who might benefit most from BCAA supplementation.
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Affiliation(s)
- Vincent W Lam
- Division of HBP Surgery, Department of Surgery, The University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China
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35
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Pfitzmann R, Nüssler NC, Hippler-Benscheidt M, Neuhaus R, Neuhaus P. Long-term results after liver transplantation. Transpl Int 2007; 21:234-46. [PMID: 18031464 DOI: 10.1111/j.1432-2277.2007.00596.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Liver transplantation (OLT) has become a successful surgical therapy for terminal liver failure. We here report about long-term results of OLT in a single center over a period of 15 years. Between 1988 and 2002, 1365 adult OLTs were performed. Mean follow-up was 103 +/- 56 months. Main indications for OLT were viral-induced cirrhosis (27.1%), alcoholic liver disease (21%), tumors (15.7%) and cholestatic liver disease (14.6%). Retransplantation was necessary in 120 (9.6%) patients because of initial nonfunction (26.9%), recurrence of underlying disease (20.2%), acute and chronic rejection (16.8%) or thrombosis of the hepatic artery (16.8%). 275 patients (22.1%) died. Causes of death included recurrence of disease (32.1%), infections (21.8%), de novo malignancies (13.5%) and cardiovascular disease (11.6%). Patient survival after OLT was 91.4%, 82.5%, 74.7% and 68.2% after 1, 5, 10 and 15 years, and graft survival was 85.8%, 75.3%, 67.3% and 61.7% after 1, 5, 10 and 15 years, respectively. Patient survival after retransplantation was 81.6%, 68.8% and 57.1% and 48.0% after 1, 5, 10 and 15 years. This analysis reveals excellent long-term results after OLT achieved in a single center.
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Affiliation(s)
- Robert Pfitzmann
- Department of General, Visceral and Transplantation Surgery, Charité, Campus Virchow-Klinikum, University Medicine Berlin, Berlin, Germany.
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Dawwas MF, Lewsey JD, Neuberger JM, Gimson AE. The impact of serum sodium concentration on mortality after liver transplantation: a cohort multicenter study. Liver Transpl 2007; 13:1115-24. [PMID: 17663412 DOI: 10.1002/lt.21154] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Modification of the current allocation system for donor livers in the United States to incorporate recipient serum sodium concentration ([Na]) has recently been proposed. However, the impact of this parameter on posttransplantation mortality has not been previously examined in a large risk-adjusted analysis. We assessed the effect of recipient [Na] on the survival of all adults with chronic liver disease who received a first single organ liver transplant in the UK and Ireland during the period March 1, 1994 to March 31, 2005 (n=5,152) at 3 years, during the first 90 days, and beyond the first 90 days, adjusting for a wide range of recipient, donor, and graft characteristics. Compared to those with normal [Na] (135-145 meq/L; n=3,066), severely hyponatremic recipients ([Na]<130 meq/L, n=541), had a higher risk-adjusted mortality at 3 years (hazard ratio [HR] 1.28; 95% confidence interval [CI], 1.04-1.59; P<0.02). The excess mortality was, however, confined to the first 90 days (HR 1.55; 95% CI, 1.18-2.04; P<0.002) with no significant difference thereafter. This was also true for hypernatremic recipients ([Na]>45 meq/L, n=81), who had an even greater risk-adjusted mortality compared to normonatremic recipients (overall: HR 1.85; 95% CI, 1.25-2.73; P<0.002; <or=90 days: HR 2.29; 95% CI, 1.42-3.70; P<0.001; >90 days: HR 1.12; 95% CI, 0.55-2.29; P=0.8), whereas mildly hyponatremic recipients ([Na] 130-134 meq/L, n=1,127) had similar risk-adjusted mortality to those with normal [Na] at the same time points. In conclusion, recipient [Na] is an independent predictor of death following liver transplantation. Attempts to correct the [Na] toward the normal reference range are an important aspect of pretransplantation management.
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Affiliation(s)
- Muhammad F Dawwas
- Hepatobiliary and Liver Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals National Health Service (NHS) Foundation Trust, Cambridge, UK.
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Khanna S, Gopalan S. Role of branched-chain amino acids in liver disease: the evidence for and against. Curr Opin Clin Nutr Metab Care 2007; 10:297-303. [PMID: 17414498 DOI: 10.1097/mco.0b013e3280d646b8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW There is ample evidence that patients with liver disease have an ongoing energy and protein catabolism. Nutritional management in these patients must receive high priority. The administration of branched-chain amino acids to patients with liver disease has been a controversial subject. This review is an update on the data available from various studies involving branched-chain amino acids supplementation in patients with chronic liver disease and associated complications. RECENT FINDINGS This review summarizes the results of nutritional interventions involving branched-chain amino acids supplementation carried out in different centres around the world. It is interesting to note that no toxic effects of branched-chain amino acids supplementation have been reported in any of these trials. SUMMARY Administration of branched-chain amino acids stimulates hepatic protein synthesis in patients with chronic liver disease and this could contribute significantly to improving their nutritional status, and result in a better quality of life. The beneficial role of branched-chain amino acids supplementation in patients with chronic hepatic encephalopathy has been clearly documented in some studies but the exact mechanism of action is still not clear.
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Affiliation(s)
- Sudeep Khanna
- Pushpawati Singhania Research Institute for Liver, Renal and Digestive Diseases, Press Enclave Road, New Delhi 110017, India.
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Pfitzmann R, Benscheidt B, Langrehr JM, Schumacher G, Neuhaus R, Neuhaus P. Trends and experiences in liver retransplantation over 15 years. Liver Transpl 2007; 13:248-57. [PMID: 17205553 DOI: 10.1002/lt.20904] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Compared to primary liver transplantation (LT), the inferior results in the outcome of liver retransplantation (re-LT) continue to be a major challenge. The purpose of this study was to analyze changes in and outcomes of re-LT over a period of 15 years at the Charité Virchow Clinic. Between 1989 and 2003, we performed 1,619 LTs and 157 re-LTs (9.7%) in 1,462 patients. A total of 119 retransplants (50 females, 69 males) were analyzed after consideration of exclusion criteria: recipient age <16 years, second re-LT, primary LT as split-liver or living-related LT, or combination with renal transplantation or Whipple operation. All patients received a whole-size organ. Mean follow-up was 62 months (6 days to 187 months). The main indications for re-LT were initial nonfunction (26.9%), recurrence of viral-induced hepatitis (20.2%), or acute and chronic rejection or thrombosis of the hepatic artery (both 16.8%). The main causes of death were bacterial infections (26.0%) as well as bleeding complications or recurrence of disease (both 16.0%) within the first postoperative month. Overall, 50 out of 119 patients (42%) died after re-LT, 26 patients within the first 3 months and 38 within 1 year. Overall patient survival was 89.9% after 1 month, 78.2% after 1 year, and 67.1% after 5 years. In conclusion, our study showed good clinical results after re-LT. Apart from the changing indications for re-LT with an increasing amount of initial organ failure and hepatic artery thrombosis, the analysis also showed a decreasing amount of complications such as rejection, ischemic type biliary lesions, and recurrence of the disease with unchanged outcome over a period of 15 years.
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Affiliation(s)
- Robert Pfitzmann
- Department of Surgery, Charité, Campus Virchow-Klinikum, Humboldt-University Berlin, Germany.
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Santoyo J, Suarez MA, Fernandez-Aguilar JL, Perez Daga JA, Sanchez-Perez B, Ramirez C, Aranda JM, Rodríguez-Canete A, Gonzalez-Sanchez A. True impact of the indication of cirrhosis and the MELD on the results of liver transplantation. Transplant Proc 2007; 38:2462-4. [PMID: 17097967 DOI: 10.1016/j.transproceed.2006.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
UNLABELLED Our Aim was to determine the impact of cirrhosis and the preoperative MELD score on the immediate postoperative mortality and hospital stay as well as survival at 1, 5, and 8 years in liver transplantation. MATERIALS AND METHODS Transplanted cirrhotic patients were selected who did not display some of the main known risk factors affecting recipient. Donor and surgical technique were included in this analysis. These exclusion criteria for recipient factors were emergency transplants and retransplants; for donor factors, age over 60 years, ischemia time over 10 hours, and moderate or severe steatosis on back-bench biopsy; and for surgery, prior complex upper abdominal surgery (mainly derivative and gastroduodenal surgery). Among 340 total liver transplants including 16 retransplants performed from March 1997 to December 2005, 197 patients met the selection criteria. The mean age of the recipients was 52 years (17-67) and the donors, 39 years (11-60). The transplant indication was cirrhosis in all cases: HCV in 69 cases (35%); alcohol in 55 (28%); hepatocarcinoma in 38 (19%); HBV in 19 (10%); PBC in 8 (4%), and other etiologies in 8 cases (4%). The MELD scores were divided as group 1, <10 points (33 cases = 17%); group 2, 10 to 18 points (136 cases = 69%); and group 3, >18 points (28 cases = 14%). The statistical analysis was performed with SPSS 11.0. RESULTS Postoperative mortality (up to 3 months) was 16 cases (8%). The median ICU and hospital stays were 3 and 13.5 days, respectively. Overall survivals at 1, 5, and 8 years were 89%, 80%, and 77%, respectively. The survival for the same periods according to MELD group was 97%, 97%, and 97% for group 1; 87%, 76%, and 72% for group 2; and 85%, 81%, and 81% for group 3 (P = NS). The survival according to the three main indications at 1, 5, and 8 years was: HCV, 91%, 80%, and 80%; alcohol, 87%, 80%, and 71%; and hepatocarcinoma, 84%, 80%, and 80% (P = NS). No significant differences were observed among early deaths between MELD groups or transplant indications. CONCLUSIONS In a favorable liver transplant setting including acceptable donors, absence of prior complex abdominal surgery in the recipient, and nonemergency transplants, neither the cause of the cirrhosis nor its severity, as measured preoperatively by the MELD, were predictive of early postoperative death or long-term survival.
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Affiliation(s)
- J Santoyo
- Unidad de Cirugía HBP y Transplante Hepático, Servicio de Cirugía General y Digestiva, Hospital Regional Universitario Carlos Haya, Malaga, Spain.
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Prieto M, Aguilera V, Berenguer M, Pina R, Benlloch S. Selección de candidatos para trasplante hepático. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:42-53. [PMID: 17266881 DOI: 10.1157/13097451] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Liver transplantation is the treatment of choice in acute and irreversible chronic liver failure of distinct etiologies. Because of the current shortage of donor organs, careful selection of candidates for transplantation is required. In addition to specific prognostic models, there are general models, such as the Child-Pugh classification and the MELD system, which are useful in determining the optimal timing of liver transplantation in most patients with cirrhosis. Once the need for transplantation has been determined and the possibility of other available therapeutic measures has been ruled out, a multidisciplinary evaluation should be performed to assess the patient's suitability for this procedure. This evaluation must rule out the presence of medical, surgical or psychological factors that could compromise patient or graft survival, making transplantation futile. The present review analyzes the most frequent contraindications to transplantation, as well as the most important aspects of pretransplantation evaluation.
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Affiliation(s)
- Martín Prieto
- Servicio de Medicina Digestiva, Hospital Universitario La Fe, Valencia, Spain.
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42
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Lewsey JD, Dawwas M, Copley LP, Gimson A, Van der Meulen JHP. Developing a prognostic model for 90-day mortality after liver transplantation based on pretransplant recipient factors. Transplantation 2006; 82:898-907. [PMID: 17038904 DOI: 10.1097/01.tp.0000235516.99977.95] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Current statistical prognostic models for mortality after liver transplantation do not have good discriminatory ability. Furthermore, the methodology used to develop these models is often flawed. The objective of this paper is to develop a prognostic model for 90-day mortality after liver transplantation based on pretransplant recipient factors, employing a rigorous model development method. METHODS We used data on 4,829 patient that were prospectively collected for the UK & Ireland Liver Transplant Audit. Switching regression was employed to impute missing values combined with a bootstrapping approach for variable selection. RESULTS In all, 452 patients (9.4%) died within 90 days of their transplantation. The final prognostic model was well calibrated and discriminated moderately well between patients who did and who did not die (c-statistic 0.65, 95% CI [0.63, 0.68]). Although discrimination was not excellent overall, the results showed that those patients with a "low" chance of dying within 90 days of their transplant and those with a "high" chance of dying could be differentiated from patients with a "intermediate" chance. CONCLUSIONS Our model can provide transplant candidates with predictions of their early posttransplantation prospects before any donor information is known, which is essential information for patients with end-stage liver disease for whom liver transplantation is a treatment option.
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Affiliation(s)
- James D Lewsey
- Health Services Research Unit, London School of Hygiene and Tropical Medicine, London, UK.
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Davis GL. Thoughts on Nutrition and Liver Disease. Nutr Clin Pract 2006; 21:243-4. [PMID: 16772541 DOI: 10.1177/0115426506021003243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Gary L Davis
- Division of Hepatology and Transplant Medicine, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA.
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Feng S, Goodrich NP, Bragg-Gresham JL, Dykstra DM, Punch JD, DebRoy MA, Greenstein SM, Merion RM. Characteristics associated with liver graft failure: the concept of a donor risk index. Am J Transplant 2006; 6:783-90. [PMID: 16539636 DOI: 10.1111/j.1600-6143.2006.01242.x] [Citation(s) in RCA: 1402] [Impact Index Per Article: 77.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Transplant physicians and candidates have become increasingly aware that donor characteristics significantly impact liver transplantation outcomes. Although the qualitative effect of individual donor variables are understood, the quantitative risk associated with combinations of characteristics are unclear. Using national data from 1998 to 2002, we developed a quantitative donor risk index. Cox regression models identified seven donor characteristics that independently predicted significantly increased risk of graft failure. Donor age over 40 years (and particularly over 60 years), donation after cardiac death (DCD), and split/partial grafts were strongly associated with graft failure, while African-American race, less height, cerebrovascular accident and 'other' causes of brain death were more modestly but still significantly associated with graft failure. Grafts with an increased donor risk index have been preferentially transplanted into older candidates (>50 years of age) with moderate disease severity (nonstatus 1 with lower model for end-stage liver disease (MELD) scores) and without hepatitis C. Quantitative assessment of the risk of donor liver graft failure using a donor risk index is useful to inform the process of organ acceptance.
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Affiliation(s)
- S Feng
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, California, USA.
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Burroughs AK, Sabin CA, Rolles K, Delvart V, Karam V, Buckels J, O'Grady JG, Castaing D, Klempnauer J, Jamieson N, Neuhaus P, Lerut J, de Ville de Goyet J, Pollard S, Salizzoni M, Rogiers X, Muhlbacher F, Garcia Valdecasas JC, Broelsch C, Jaeck D, Berenguer J, Gonzalez EM, Adam R. 3-month and 12-month mortality after first liver transplant in adults in Europe: predictive models for outcome. Lancet 2006; 367:225-32. [PMID: 16427491 DOI: 10.1016/s0140-6736(06)68033-1] [Citation(s) in RCA: 234] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Mortality after liver transplantation depends on heterogeneous recipient and donor factors. Our aim was to assess risk of death and to develop models to help predict mortality after liver transplantation. METHODS We analysed data from 34,664 first adult liver transplants from the European Liver Transplant Registry to identify factors associated with mortality at 3-months (n=21,605 in training dataset) and 12-months (n=18,852 in training dataset) after transplantation. We used multivariable logistic regression models to generate mortality scores for each individual, and assessed model discrimination and calibration on an independent validation dataset (n=9489 for 3-month model and n=8313 for 12-month model). FINDINGS 2540 of 21,605 (12%) individuals in the 3-month training sample had died by 3 months. Compared with those transplanted in 2000-03, those transplanted earlier had a higher risk of death. Increased mortality at 3-months post-transplantation was associated with acute liver failure (adjusted odds ratio 1.61), donor age older than 60 years (1.16), compatible (1.22) or incompatible (2.07) donor-recipient blood group, older recipient age (1.12 per 5 years), split or reduced graft (1.96), total ischaemia time of longer than 13 h (1.38), and low United Network for Organ Sharing score (score 1: 2.43; score 2: 1.67). However, cirrhosis with hepatocellular carcinoma, alcohol cirrhosis, hepatitis C or primary biliary cirrhosis, donor age 40 years or younger, or less, hepatitis B, and larger size of transplant centre (> or = 70 transplants per year) were associated with improved early outcomes. The 3-month mortality score discriminated well between those who did and did not die in the validation sample (C statistic=0.688). We noted similar findings for 12-month mortality, although deaths were generally underestimated at this timepoint. INTERPRETATION The 3-month and 12-month mortality models can be effectively used to assess outcomes both within and between centres. Furthermore, the models provide a means of assessing the risk of post-transplantation mortality, giving clinicians important data on which to base strategic decisions about transplant policy in particular individuals or groups.
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Affiliation(s)
- Andrew K Burroughs
- Liver Transplantation and Hepatobiliary Medicine, Royal Free Hampstead NHS Trust, London NW3 2QG, UK
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46
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Shah T, Lai WK, Gow P, Leeming J, Mutimer D. Low-dose amphotericin for prevention of serious fungal infection following liver transplantation. Transpl Infect Dis 2005; 7:126-32. [PMID: 16390401 DOI: 10.1111/j.1399-3062.2005.00108.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS This study advances previously performed clinical studies of antifungal prophylaxis and prospectively evaluates the efficacy of low-dose amphotericin B preparations for the prevention of invasive fungal infection (IFI) in high-risk liver transplant (LT) recipients. METHODS High-risk LT patients were recruited and randomised to openly receive intravenously either conventional amphotericin B (amB) at a dose of 15 mg daily, or liposomal amphotericin B (amBisome) 50 mg daily. Prophylaxis was continued until discharge from the intensive care unit (ICU), until patient death, or until time of conversion to high-dose amBisome for treatment of suspected or confirmed IFI. RESULTS During the study period, 360 adult LTs were performed; 132 patients were eligible for 149 recruitment episodes into the trial, and 83 patients were recruited for 92 episodes. Of the 92, 48 patient episodes were randomised to receive amBisome prophylaxis, and 44 to receive amB. IFI was uncommon, diagnosed for 3 patients in the amBisome group, and for 2 in the amB group. Furthermore, Aspergillus was isolated on a single occasion during 92 episodes of prophylaxis. Fungal colonisation scores did not differ significantly between the 2 groups. There was a significant difference in the rates of survival to ICU discharge between the 2 groups (79.6% amBisome vs. 59.5% amB, P=0.038). Renal function measures including creatinine clearance at commencement and conclusion of prophylaxis, and at 12 months post transplant were not statistically different between the 2 groups. CONCLUSION The use of amphotericin B, liposomal or non-liposomal preparations at low doses, for prophylaxis of IFI in high-risk LT patients, is associated with a low incidence of serious fungal infection. In this randomised study, low-dose amBisome prophylaxis was associated with an increased likelihood of successful discharge from the ICU.
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Affiliation(s)
- T Shah
- Liver and Hepatobiliary Unit, Queen Elizabeth Hospital, Birmingham, UK.
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47
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Jacob M, Lewsey JD, Sharpin C, Gimson A, Rela M, van der Meulen JHP. Systematic review and validation of prognostic models in liver transplantation. Liver Transpl 2005; 11:814-825. [PMID: 15973726 DOI: 10.1002/lt.20456] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A model that can accurately predict post-liver transplant mortality would be useful for clinical decision making, would help to provide patients with prognostic information, and would facilitate fair comparisons of surgical performance between transplant units. A systematic review of the literature was carried out to assess the quality of the studies that developed and validated prognostic models for mortality after liver transplantation and to validate existing models in a large data set of patients transplanted in the United Kingdom (UK) and Ireland between March 1994 and September 2003. Five prognostic model papers were identified. The quality of the development and validation of all prognostic models was suboptimal according to an explicit assessment tool of the internal, external, and statistical validity, model evaluation, and practicality. The discriminatory ability of the identified models in the UK and Ireland data set was poor (area under the receiver operating characteristic curve always smaller than 0.7 for adult populations). Due to the poor quality of the reporting, the methodology used for the development of the model could not always be determined. In conclusion, these findings demonstrate that currently available prognostic models of mortality after liver transplantation can have only a limited role in clinical practice, audit, and research.
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Affiliation(s)
- Matthew Jacob
- Health Services Research Unit, London School of Hygiene and Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - James D Lewsey
- Health Services Research Unit, London School of Hygiene and Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Carlos Sharpin
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | | | - Mohammed Rela
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Jan H P van der Meulen
- Health Services Research Unit, London School of Hygiene and Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
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48
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Marchesini G, Marzocchi R, Noia M, Bianchi G. Branched-chain amino acid supplementation in patients with liver diseases. J Nutr 2005; 135:1596S-601S. [PMID: 15930476 DOI: 10.1093/jn/135.6.1596s] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Because of their peculiar role in whole-body nitrogen metabolism and the competitive action on amino acid transport across the blood-brain barrier, branched-chain amino acids (BCAAs) have been extensively used in subjects with liver disease to preserve or to restore muscle mass and to improve hepatic encephalopathy. There are no data regarding safe limits of BCAA administration; the results appear to be better when BCAA-enriched formulas or BCAA-supplemented diets are preferred to pure BCAA formulas. Improved nitrogen retention might ameliorate the nutritional status, a prognostic index of long-term survival in cirrhosis and of short-term survival in patients undergoing surgical procedures. The effects on nutrition and ultimately on prognosis of patients with advanced cirrhosis were confirmed in a large multicenter, long-term trial where oral BCAA supplements were compared with equicaloric or equinitrogenous-equicaloric supplements (maltodextrin or lactoalbumin). Similarly, BCAA treatment improved the prognosis of patients with hepatocellular carcinoma, treated by surgical resection or chemoembolization, and of liver transplant patients. The mechanism(s) for the beneficial effects of BCAAs might be mediated by their stimulating activity on hepatocyte growth factor, favoring liver regeneration. The debate regarding the potential effectiveness of BCAAs dates back to the early 1980s. The number of patients who cannot tolerate dietary proteins in amounts sufficient to meet the higher catabolism of advanced liver disease is probably low, but BCAAs remain the sole treatment of proved efficacy in this specific setting.
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Affiliation(s)
- Giulio Marchesini
- Department of Internal Medicine, Alma Mater Studiorum, University of Bologna, Italy.
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49
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Northup PG, Berg CL. Preoperative delta-MELD score does not independently predict mortality after liver transplantation. Am J Transplant 2004; 4:1643-9. [PMID: 15367219 DOI: 10.1111/j.1600-6143.2004.00593.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Changes in model for end-stage liver disease (MELD) score of > or = 5 points over 30 days (delta-MELD) is an independent predictor for death in patients awaiting liver transplantation. The aim of the current study was to determine if a positive change in MELD score occurring over the 30 days immediately prior to liver transplantation was predictive of posttransplant mortality. MELD scores from the day of transplantation and 30 days prior to transplantation were calculated for 1510 UNOS patients and used to compute a delta-MELD score. Multivariate modeling determined predictors of posttransplant mortality. Patients with a preoperative delta-MELD > or = 5 had higher absolute MELD scores at transplant, shorter mean posttransplant survival and higher mortality. However, multivariate analysis showed that none of the excess mortality was attributable to the high delta-MELD score (p = 0.43 for delta-MELD > or = 5) and the majority of the excess risk was attributable to absolute MELD score (p < 0.001) at the time of transplantation. Mortality of patients with rapidly worsening chronic liver disease who undergo transplantation depends substantially on absolute MELD score at the time of transplantation but not the rate of change immediately preceding transplant. Allocation policymakers should consider that a high delta-MELD in the immediate pretransplant period does not indicate greater posttransplant mortality.
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Affiliation(s)
- Patrick G Northup
- Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, VA, USA.
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50
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Lama C, Figueras J. [Improvement in postoperative morbidity and mortality in liver transplantation]. Med Clin (Barc) 2004; 123:340-1. [PMID: 15388037 DOI: 10.1016/s0025-7753(04)74509-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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