1
|
Wang R, Wang L, Jiang Y, Dong M, Li M, Sun P. Sarcopenia as a prognostic factor in patients with hepatocellular carcinoma treated with transcatheter arterial chemoembolization plus sorafenib. J Cancer Res Ther 2024; 20:1208-1213. [PMID: 39206983 DOI: 10.4103/jcrt.jcrt_2451_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 04/01/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Loss of skeletal muscle volume is an important aspect of sarcopenia in hepatocellular carcinoma (HCC) patients treated by surgical resection, transcatheter arterial chemoembolization (TACE), or sorafenib. PURPOSE This study determined the influence of sarcopenia and other laboratory results on survival in patients with HCC treated with TACE plus sorafenib. METHODS The patients were divided into two groups based on the presence of sarcopenia. The skeletal muscle index was calculated by normalizing the cross-sectional muscle area at the L3 level on an abdominal computed tomography scan before embolization according to the patient's height. The clinical characteristics of the two groups were then compared. The progression-free survival (PFS) and overall survival (OS) rates after treatment were determined. RESULTS Sarcopenia was present in 75 of the 102 (74%) patients with HCC included in this study. The albumin, prealbumin, and cholinesterase levels were lower in those with sarcopenia. The OS (P = 0.001) and PFS (P = 0.008) were significantly prolonged in the nonsarcopenia group compared to the sarcopenia group. Sarcopenia, ECOG (≥2), and prealbumin (<180 mg/L) were significantly associated with PFS. Sarcopenia, ECOG (≥2), Child-Pugh B, BCLC stage C, prealbumin (<180 mg/L), and cholinesterase (<5,320 U/L) were significantly associated with OS. The prognostic factors for OS included sarcopenia, ECOG (≥2), and cholinesterase (<5,320 U/L), whereas only ECOG (≥2) was identified as a prognostic factor for PFS. CONCLUSION Sarcopenia may be an indicator of poor clinical outcome in patients with HCC receiving TACE plus sorafenib.
Collapse
Affiliation(s)
- Rujian Wang
- Department of Interventional Therapy, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, P.R. China
| | - Ligang Wang
- Department of Interventional Therapy, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, P.R. China
| | - Yutian Jiang
- Department of Interventional Therapy, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, P.R. China
| | - Mei Dong
- Department of Cardiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, P.R. China
| | - Mei Li
- Department of General Medicine, Yantaishan Hospital, Yantai, Shandong, P.R. China
| | - Ping Sun
- Department of Oncology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, P.R. China
| |
Collapse
|
2
|
Stämmler F, Derain-Dubourg L, Lemoine S, Meeusen JW, Dasari S, Lieske JC, Robertson A, Schiffer E. Impact of race-independent equations on estimating glomerular filtration rate for the assessment of kidney dysfunction in liver disease. BMC Nephrol 2023; 24:83. [PMID: 37003973 PMCID: PMC10064726 DOI: 10.1186/s12882-023-03136-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/23/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Altered hemodynamics in liver disease often results in overestimation of glomerular filtration rate (GFR) by creatinine-based GFR estimating (eGFR) equations. Recently, we have validated a novel eGFR equation based on serum myo-inositol, valine, and creatinine quantified by nuclear magnetic resonance spectroscopy in combination with cystatin C, age and sex (GFRNMR). We hypothesized that GFRNMR could improve chronic kidney disease (CKD) classification in the setting of liver disease. RESULTS We conducted a retrospective multicenter study in 205 patients with chronic liver disease (CLD), comparing the performance of GFRNMR to that of validated CKD-EPI eGFR equations, including eGFRcr (based on creatinine) and eGFRcr-cys (based on both creatinine and cystatin C), using measured GFR as reference standard. GFRNMR outperformed all other equations with a low overall median bias (-1 vs. -6 to 4 ml/min/1.73 m2 for the other equations; p < 0.05) and the lowest difference in bias between reduced and preserved liver function (-3 vs. -16 to -8 ml/min/1.73 m2 for other equations). Concordant classification by CKD stage was highest for GFRNMR (59% vs. 48% to 53%) and less biased in estimating CKD severity compared to the other equations. GFRNMR P30 accuracy (83%) was higher than that of eGFRcr (75%; p = 0.019) and comparable to that of eGFRcr-cys (86%; p = 0.578). CONCLUSIONS Addition of myo-inositol and valine to creatinine and cystatin C in GFRNMR further improved GFR estimation in CLD patients and accurately stratified liver disease patients into CKD stages.
Collapse
Affiliation(s)
- Frank Stämmler
- Department of Research and Development, Numares AG,, Am BioPark 9, 93053, Regensburg, Germany
| | - Laurence Derain-Dubourg
- Department Néphrologie, Dialyse, Hypertension Et Exploration Fonctionnelle Rénale, Groupement Hospitalier Edouard Herriot, Hospices Civils de Lyon, Université Claude Bernard, Lyon 1, Lyon, France
| | - Sandrine Lemoine
- Department Néphrologie, Dialyse, Hypertension Et Exploration Fonctionnelle Rénale, Groupement Hospitalier Edouard Herriot, Hospices Civils de Lyon, Université Claude Bernard, Lyon 1, Lyon, France
| | - Jeffrey W Meeusen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Surendra Dasari
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - John C Lieske
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Andrew Robertson
- Department of Research and Development, Numares AG,, Am BioPark 9, 93053, Regensburg, Germany
| | - Eric Schiffer
- Department of Research and Development, Numares AG,, Am BioPark 9, 93053, Regensburg, Germany.
| |
Collapse
|
3
|
Stockhoff L, Muellner-Bucsics T, Markova AA, Schultalbers M, Keimburg SA, Tergast TL, Hinrichs JB, Simon N, Gerbel S, Manns MP, Mandorfer M, Cornberg M, Meyer BC, Wedemeyer H, Reiberger T, Maasoumy B. Low Serum Cholinesterase Identifies Patients With Worse Outcome and Increased Mortality After TIPS. Hepatol Commun 2022; 6:621-632. [PMID: 34585537 PMCID: PMC8870033 DOI: 10.1002/hep4.1829] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/29/2021] [Accepted: 08/30/2021] [Indexed: 12/14/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for portal hypertension-related complications. However, careful selection of patients is crucial. The aim of this study was to evaluate the prognostic value of serum cholinesterase (CHE) for outcomes and mortality after TIPS insertion. In this multicenter study, 389 consecutive patients with cirrhosis receiving a TIPS at Hannover Medical School, University Hospital Essen, or Medical University of Vienna were included. The Hannover cohort (n = 200) was used to initially explore the role of CHE, whereas patients from Essen and Vienna served as a validation cohort (n = 189). Median age of the patients was 58 years and median Model for End-Stage Liver Disease (MELD) score was 12. Multivariable analysis identified MELD score (hazard ratio [HR]: 1.16; P < 0.001) and CHE (HR: 0.61; P = 0.008) as independent predictors for 1-year survival. Using the Youden Index, a CHE of 2.5 kU/L was identified as optimal threshold to predict post-TIPS survival in the Hannover cohort (P < 0.001), which was confirmed in the validation cohort (P = 0.010). CHE < 2.5 kU/L was significantly associated with development of acute-on-chronic liver failure (P < 0.001) and hepatic encephalopathy (P = 0.006). Of note, CHE was also significantly linked to mortality in the subgroup of patients with refractory ascites (P = 0.001) as well as in patients with high MELD scores (P = 0.012) and with high-risk FIPS scores (P = 0.004). After propensity score matching, mortality was similar in patients with ascites and CHE < 2.5 kU/L if treated by TIPS or by paracentesis. Contrarily, in patients with CHE ≥ 2.5 kU/L survival was significantly improved by TIPS as compared to treatment with paracentesis (P < 0.001). Conclusion: CHE is significantly associated with mortality and complications after TIPS insertion. Therefore, we suggest that CHE should be evaluated as an additional parameter for selecting patients for TIPS implantation.
Collapse
Affiliation(s)
- Lena Stockhoff
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Theresa Muellner-Bucsics
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Vienna Hepatic Hemodynamic LaboratoryMedical University of ViennaViennaAustria
| | - Antoaneta A Markova
- Department of Gastroenterology and HepatologyUniversity Hospital EssenEssenGermany
| | - Marie Schultalbers
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Simone A Keimburg
- Department of Gastroenterology and HepatologyUniversity Hospital EssenEssenGermany
| | - Tammo L Tergast
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Jan B Hinrichs
- Institute for Diagnostic and Interventional RadiologyHannover Medical SchoolHannoverGermany
| | - Nicolas Simon
- Center for Information Management (ZIMt)Hannover Medical SchoolHannoverGermany
| | - Svetlana Gerbel
- Center for Information Management (ZIMt)Hannover Medical SchoolHannoverGermany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Mattias Mandorfer
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Vienna Hepatic Hemodynamic LaboratoryMedical University of ViennaViennaAustria
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - Bernhard C Meyer
- Institute for Diagnostic and Interventional RadiologyHannover Medical SchoolHannoverGermany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany.,Department of Gastroenterology and HepatologyUniversity Hospital EssenEssenGermany
| | - Thomas Reiberger
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria.,Vienna Hepatic Hemodynamic LaboratoryMedical University of ViennaViennaAustria
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| |
Collapse
|
4
|
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.
Collapse
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
| | | |
Collapse
|
5
|
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.
Collapse
|
6
|
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.
Collapse
|
7
|
Matsuo M, Yamagami T. Low serum cholinesterase predicts complication risk after orthopedic surgery in elderly patients: an observational pilot study. JA Clin Rep 2019; 5:39. [PMID: 32025927 PMCID: PMC6967189 DOI: 10.1186/s40981-019-0259-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Serum cholinesterase (ChE) in elderly adults is associated with geriatric conditions such as sarcopenia and malnutrition. The aim of this study is to examine the impact of preoperative serum ChE on the development of complications after noncardiac surgery in elderly patients without liver cirrhosis. METHODS We retrospectively identified all patients aged ≥ 65 years who underwent orthopedic surgery over a 1.5-year period in our hospital. The main outcome was postoperative complications, defined as a deviation from the normal postoperative course within 30 days postoperatively. RESULTS A total of 313 patients (median age 79 years) were included. The incidence of all-cause postoperative complications was 15.7% (49/313 patients). Receiver operating characteristic curve analysis showed that serum ChE was a univariable factor that predicted all-cause complications with moderate accuracy (area under the curve = 0.694, 95% confidence interval (CI) 0.604-0.783), with an optimal serum ChE cutoff level of 200 units/L. After multivariate analyses adjusted by baseline characteristics, low serum ChE remained a significant risk factor for postoperative complications (odds ratio = 2.99, 95% CI 1.41-6.33, P = 0.004). CONCLUSIONS Low serum ChE (< 200 unit/L) is a significant risk factor for postoperative complications after orthopedic surgery in patients aged ≥ 65 years.
Collapse
Affiliation(s)
- Mitsuhiro Matsuo
- Department of Anesthesiology, Itoigawa General Hospital, 457-1 Takegahana, Itoigawa, Niigata, 941-8502, Japan.
| | - Tohru Yamagami
- Department of Orthopedic Surgery, Itoigawa General Hospital, Itoigawa, Niigata, Japan
| |
Collapse
|
8
|
Jeschke B, Gottlieb A, Sowa JP, Jeschke S, Treckmann JW, Gerken G, Canbay A. Single-Center Retrospective Study of Clinical and Laboratory Features That Predict Survival of Patients With Budd-Chiari Syndrome After Liver Transplant. EXP CLIN TRANSPLANT 2019; 17:665-672. [PMID: 31050620 DOI: 10.6002/ect.2018.0274] [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 Budd-Chiari syndrome is a rare but critical condition that can progress to liver failure and death. For severe cases, orthotopic liver transplant remains the only curative option. The present study aimed to identify predictive parameters to assess outcomes of liver transplant. MATERIALS AND METHODS Medical records of 33 individuals with Budd-Chiari syndrome who received orthotopic liver transplant were retrospectively assessed. Twenty-seven eligible patients were identified and grouped by outcome (survived/deceased) after transplant for Budd-Chiari syndrome. Demographic, clinical, and serum parameters taken at the time of Budd-Chiari syndrome diagnosis were evaluated for prognostic value. RESULTS Differences between patients who survived and those who died were found for nausea/vomiting (P < .01) and splenomegaly (P < .01), which were both more common in patients who died after transplant. In addition, patients in the deceased group exhibited significantly lower serum cholinesterase levels (P < .01) and higher alkaline phosphatase levels (P < .01). Scoring systems to assess liver status or Budd-Chiari syndrome severity (Model for End-Stage Liver Disease and Child-Pugh scores, Rotterdam score, and the transjugular intrahepatic portosystemic shunting prognostic index) did not differ between groups. CONCLUSIONS Nausea/vomiting, splenomegaly, low serum cholinesterase, and high alkaline phosphatase were associated with adverse outcomes after orthotopic liver transplant for Budd-Chiari syndrome. These factors may be surrogate markers for a severely impaired health status at time of diagnosis and should be evaluated prospectively in larger cohorts.
Collapse
Affiliation(s)
- Barbara Jeschke
- the Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | | | | | | | | | | | | |
Collapse
|
9
|
Clinical Aspects and Prognosis Evaluation of Cirrhotic Patients Hospitalized with Acute Kidney Injury. Can J Gastroenterol Hepatol 2019; 2019:6567850. [PMID: 30941330 PMCID: PMC6421012 DOI: 10.1155/2019/6567850] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/18/2018] [Accepted: 01/15/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Acute kidney injury occurs in approximately 20% of hospitalized cirrhotic patients. Mortality is estimated at 60% within a month and 65% within a year. AIMS To evaluate survival in 30 days and in 3 months of cirrhotic patients hospitalized with acute kidney injury, identifying factors associated with mortality. METHODS 52 patients with cirrhosis admitted to an academic tertiary center who presented acute kidney injury according to the International Club of Ascites criteria were evaluated. Clinical and laboratory data was collected at diagnosis between 2011 and 2015. RESULTS Average age was 54.6 (±10.7) years and 69.2% were male. The average MELD, MELD-Na, and Child-Pugh scores were 21.9 (±7.0), 24.5 (±6.7), and 10.1 (±2.2), respectively. Thirty patients (57.7%) were in acute kidney injury stage 1, 16 (30.8%) in stage 2, and six (11.6%) in stage 3. Mortality was 28.6% in 30 days and 44.9% in three months. In multivariate analysis, variables that were associated independently to mortality were lack of response to expansion treatment and Child-Pugh score. Mortality was 93.3% in three months among nonresponders compared to 28.6% among those who responded to volume expansion (p<0.0001). CONCLUSION Acute kidney injury in cirrhosis has dire prognosis, particularly in patients with advanced cirrhosis and in nonresponders to volume expansion.
Collapse
|
10
|
Artzner T, Michard B, Besch C, Levesque E, Faitot F. Liver transplantation for critically ill cirrhotic patients: Overview and pragmatic proposals. World J Gastroenterol 2018; 24:5203-5214. [PMID: 30581269 PMCID: PMC6295835 DOI: 10.3748/wjg.v24.i46.5203] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation for critically ill cirrhotic patients with acute deterioration of liver function associated with extrahepatic organ failures is controversial. While transplantation has been shown to be beneficial on an individual basis, the potentially poorer post-transplant outcome of these patients taken as a group can be held as an argument against allocating livers to them. Although this issue concerns only a minority of liver transplants, it calls into question the very heart of the allocation paradigms in place. Indeed, most allocation algorithms have been centered on prioritizing the sickest patients by using the model for end-stage liver disease score. This has led to allocating increasing numbers of livers to increasingly critically ill patients without setting objective or consensual limits on how sick patients can be when they receive an organ. Today, finding robust criteria to deem certain cirrhotic patients too sick to be transplanted seems urgent in order to ensure the fairness of our organ allocation protocols. This review starts by fleshing out the argument that finding such criteria is essential. It examines five types of difficulties that have hindered the progress of recent literature on this issue and identifies various strategies that could be followed to move forward on this topic, taking into account the recent discussion on acute on chronic liver failure. We move on to review the literature along four axes that could guide clinicians in their decision-making process regarding transplantation of critically ill cirrhotic patients.
Collapse
Affiliation(s)
- Thierry Artzner
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
| | - Baptiste Michard
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
| | - Camille Besch
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
| | - Eric Levesque
- Service d’Anesthésie et Réanimation Chirurgicale, Hôpital Henri Mondor, Créteil 94000, France
| | - François Faitot
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
| |
Collapse
|
11
|
Lindenmeyer CC, Kim A, Sanghi V, Lopez R, Niyazi F, Mehta NA, Flocco G, Kapoor A, Carey WD, Romero-Marrero C. The EMALT Score: An Improved Model for Prediction of Early Mortality in Liver Transplant Recipients. J Intensive Care Med 2018; 35:781-788. [PMID: 29996705 DOI: 10.1177/0885066618784869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE Needs, risks, and outcomes of patients admitted to a post liver transplant intensive care unit (POLTICU) differ in important ways from those admitted to pretransplant intensive care units (ICUs). The aim of this study was to create the optimal model to risk stratify POLTICU patients. METHODS Consecutive patients who underwent first deceased donor liver transplantation (LT) at a large United States center between 2008 and 2014 were followed from admission to LT and to discharge or death. Receiver-operating characteristic analysis was performed to assess the value of various scores in predicting in-hospital mortality. A predictive model was developed using logistic regression analysis. RESULTS A total of 697 patients underwent LT, and 3.2% died without leaving the hospital. A model for in-hospital mortality was derived from variables available within 24 hours of admission to the POLTICU. Key variables best predicting survival were white blood cell count, 24-hour urine output, and serum glucose. A model using these variables performed with an area under the curve (AUC) of 0.88, compared to the Acute Physiology and Chronic Health Evaluation III and Model for End-Stage Liver Disease, which performed with AUCs of 0.74 and 0.60, respectively. CONCLUSION An improved model, the early mortality after LT (EMALT) score, performs better than conventional models in predicting in-hospital mortality after LT.
Collapse
Affiliation(s)
| | - Ahyoung Kim
- Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Vedha Sanghi
- Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Fadi Niyazi
- Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Neal A Mehta
- Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Gianina Flocco
- Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Aanchal Kapoor
- Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - William D Carey
- Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | | |
Collapse
|
12
|
Aljumah AA, Tamim H, Saeed M, Tamimi W, Alfawaz H, Al Qurashi S, Al Dawood A, Al Sayyari A. The Role of Urinary Neutrophil Gelatinase-Associated Lipocalin in Predicting Acute Kidney Dysfunction in Patients With Liver Cirrhosis. J Clin Med Res 2018; 10:419-428. [PMID: 29581805 PMCID: PMC5862090 DOI: 10.14740/jocmr3366w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 02/26/2018] [Indexed: 12/16/2022] Open
Abstract
Background Early detection of acute kidney dysfunction (AKD) in cirrhotic patients is crucial. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) has been identified as an early marker of AKD. The aim of the study was to evaluate serial uNGAL as a marker and predictor of AKD in liver cirrhosis patients. Methods Serial uNGAL and serum creatinine (sCr) levels were measured daily during the first 6 days of admission. Furthermore, sCr levels and the estimated glomerular filtration rate (eGFR) were measured after 3 - 6 weeks. The uNGAL levels in patients with and without abnormal sCr were compared. Results Fifty-seven consecutive cirrhotic patients were enrolled in the study. Eight of 14 patients (57%) who developed abnormal uNGAL level also had abnormal sCr level (odds ratio (OR) = 3.4, 95% CI: 0.99 - 12.03, P = 0.05). After 6 weeks, 41% of patients exhibited an abnormal uNGAL level and abnormal sCr (OR = 6.7, 95% CI: 1.55 - 28.85, P = 0.01). Area under the curve (AUROC) and the best cut-off point for highest NGAL in 6 days were 0.64 and 72.55 ng/mL, respectively. Conclusions There is a modest association between highest uNGAL in the first 6 days of admission and sCr at week 6 in all participants. This may indicate that in cirrhotic patients, uNGAL level during the first 6 days of admission has a potential predictability for the development of high sCr and low eGFR 6 weeks later. The AUROC of 0.64 quantifies the overall ability of uNGAL to discriminate between those individuals who will have a raised sCr levels and those who will not.
Collapse
Affiliation(s)
- Abdulrahman A Aljumah
- Hepatology Division, Department of Organ Transplant and Hepatobiliary Sciences, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Mohamed Saeed
- Hepatology Division, Department of Organ Transplant and Hepatobiliary Sciences, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Waleed Tamimi
- King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,Pathology & Laboratory Medicine, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Hanan Alfawaz
- Department of Food Science and Nutrition, College of Food Science and Agriculture, King Saud University, Riyadh, Saudi Arabia.,Prince Mutaib Chair for Biomarkers of Osteoporosis, King Saud University, Riyadh, Saudi Arabia
| | - Salem Al Qurashi
- King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,Nephrology and Renal Transplantation Division, Department of Medicine, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulaziz Al Dawood
- King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,Department of Intensive Care, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulla Al Sayyari
- King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,Nephrology and Renal Transplantation Division, Department of Medicine, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| |
Collapse
|
13
|
Schlegel A, Linecker M, Kron P, Györi G, De Oliveira ML, Müllhaupt B, Clavien PA, Dutkowski P. Risk Assessment in High- and Low-MELD Liver Transplantation. Am J Transplant 2017; 17:1050-1063. [PMID: 27676319 DOI: 10.1111/ajt.14065] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/23/2016] [Accepted: 09/21/2016] [Indexed: 01/25/2023]
Abstract
Allocation of liver grafts triggers emotional debates, as those patients, not receiving an organ, are prone to death. We analyzed a high-Model of End-stage Liver Disease (MELD) cohort (laboratory MELD score ≥30, n = 100, median laboratory MELD score of 35; interquartile range 31-37) of liver transplant recipients at our center during the past 10 years and compared results with a low-MELD group, matched by propensity scoring for donor age, recipient age, and cold ischemia time. End points of our study were cumulative posttransplantation morbidity, cost, and survival. Six different prediction models, including donor age x recipient MELD (D-MELD), Difference between listing MELD and MELD at transplant (Delta MELD), donor-risk index (DRI), Survival Outcomes Following Liver Transplant (SOFT), balance-of-risk (BAR), and University of California Los Angeles-Futility Risk Score (UCLA-FRS), were applied in both cohorts to identify risk for poor outcome and high cost. All score models were compared with a clinical-oriented decision, based on the combination of hemofiltration plus ventilation. Median intensive care unit and hospital stays were 8 and 26 days, respectively, after liver transplantation of high-MELD patients, with a significantly increased morbidity compared with low-MELD patients (median comprehensive complication index 56 vs. 36 points [maximum points 100] and double cost [median US$179 631 vs. US$80 229]). Five-year survival, however, was only 8% less than that of low-MELD patients (70% vs. 78%). Most prediction scores showed disappointing low positive predictive values for posttransplantation mortality, such as mortality above thresholds, despite good specificity. The clinical observation of hemofiltration plus ventilation in high-MELD patients was even superior in this respect compared with D-MELD, DRI, Delta MELD, and UCLA-FRS but inferior to SOFT and BAR models. Of all models tested, only the BAR score was linearly associated with complications. In conclusion, the BAR score was most useful for risk classification in liver transplantation, based on expected posttransplantation mortality and morbidity. Difficult decisions to accept liver grafts in high-risk recipients may thus be guided by additional BAR score calculation, to increase the safe use of scarce organs.
Collapse
Affiliation(s)
- A Schlegel
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - M Linecker
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - P Kron
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - G Györi
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - M L De Oliveira
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - B Müllhaupt
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - P-A Clavien
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - P Dutkowski
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| |
Collapse
|
14
|
Clayton DB, Palmer WC, Robison SW, Heckman MG, Chimato NT, Harnois DM, Francis DL. Colonoscopy bowel preparation quality improvement for patients with decompensated cirrhosis undergoing evaluation for liver transplantation. Clin Transplant 2016; 30:1236-1241. [DOI: 10.1111/ctr.12809] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2016] [Indexed: 01/14/2023]
Affiliation(s)
| | | | | | - Michael G. Heckman
- Division of Biomedical Statistics and Informatics; Mayo Clinic; Jacksonville FL USA
| | - Nicolette T. Chimato
- Division of Biomedical Statistics and Informatics; Mayo Clinic; Jacksonville FL USA
| | | | - Dawn L. Francis
- Gastroenterology and Hepatology; Mayo Clinic; Jacksonville FL USA
| |
Collapse
|
15
|
Ney M, Haykowsky MJ, Vandermeer B, Shah A, Ow M, Tandon P. Systematic review: pre- and post-operative prognostic value of cardiopulmonary exercise testing in liver transplant candidates. Aliment Pharmacol Ther 2016; 44:796-806. [PMID: 27539029 DOI: 10.1111/apt.13771] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 07/15/2016] [Accepted: 07/28/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) is the gold standard for the objective assessment of functional status. In many conditions, CPET outperforms the traditional variables in predicting mortality. AIM In patients with cirrhosis listed for liver transplantation, our primary aim was to determine the prognostic value of CPET for pre-and post-transplant mortality and, in particular, whether CPET remained predictive after adjustment for liver disease severity. METHODS A systematic literature review was conducted in databases Medline, Scopus, Embase and PubMed. Where possible, data were pooled for meta-analyses using a DerSimonian and Laird random effects model. RESULTS A total of seven studies were retrieved, including 1107 patients with a mean MELD of 14.2 (standard deviation 1.6) and peak baseline VO2 of 17.4 mL/kg/min. In all of the studies in which multivariable analysis was performed, CPET variables were independent predictors of pre-transplant mortality (three studies) and post-transplant mortality (four studies). In the three studies where we could aggregate post-transplant mortality data, post-transplant mortality was predicted by AT with a mean difference of 2.0 (95% confidence interval, CI: 0.42-3.59; Z = 2.48, P = 0.01) between survivors and nonsurvivors. The peak VO2 was not significant (0.77 95% CI: -1.36 to 2.90; Z = 0.71, P = 0.48). CONCLUSIONS Patient's listed for liver transplant have significant functional limitations, with a weighted mean VO2 below the threshold level required for independent living. Although heterogeneity in study designs with respect to timing, CPET variables, and cut-off values precluded the determination of CPET mortality thresholds, the studies support CPET as an objective and independent predictor of pre- and post-transplant mortality.
Collapse
Affiliation(s)
- M Ney
- Cirrhosis Care Clinic, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Centre of Excellence for Gastrointestinal Inflammation and Immunity Research (CEGIIR), University of Alberta, Edmonton, AB, Canada
| | - M J Haykowsky
- College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, TX, USA
| | - B Vandermeer
- Alberta Research Centre for Health Evidence (ARCHE), Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - A Shah
- Cirrhosis Care Clinic, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Centre of Excellence for Gastrointestinal Inflammation and Immunity Research (CEGIIR), University of Alberta, Edmonton, AB, Canada
| | - M Ow
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - P Tandon
- Cirrhosis Care Clinic, Department of Medicine, University of Alberta, Edmonton, AB, Canada. .,Centre of Excellence for Gastrointestinal Inflammation and Immunity Research (CEGIIR), University of Alberta, Edmonton, AB, Canada.
| |
Collapse
|
16
|
Abstract
Donor organs for transplantations are a scarce commodity; therefore, allocation systems are needed that guarantee an ethically acceptable distribution to patients on the waiting list (equal treatment and fairness) but also take the probability of survival of the transplant in each recipient into consideration. In this article the allocation systems for lung, liver, kidney and pancreas transplants are presented.For lung transplantations an allocation system based on the lung allocation score (LAS) is currently used. The LAS predicts the probability of survival on the waiting list and the survival rate following transplantation. Organs with a limited range of utilization are distributed in a so-called mini-match procedure.For post-mortem kidney and pancreas transplantations a relatively complex but transparent allocation system has been created in which patients are subdivided into groups, each of which has its own allocation rules. The allocation is principally carried out according to criteria of fairness of distribution and according to the prospects of success. The probability of a mismatch also plays a role. The urgency is important for children and for patients who do not have the possibility of dialysis. Combined pancreas and kidney transplantations have priority over kidney transplantations alone.The criterion for the urgency of liver transplantation in Germany is currently the model for end-stage liver disease (MELD), which aims to reduce the waiting list mortality and to prioritize transplantations for those most in need. Because the system insufficiently describes the priority of transplantation for patients with tumors or genetic liver diseases, there is an additional set of rules for so-called standard exceptions.
Collapse
|
17
|
Haddad L, Cassenote AJF, Andraus W, de Martino RB, Ortega NRDS, Abe JM, D’Albuquerque LAC. Factors Associated with Mortality and Graft Failure in Liver Transplants: A Hierarchical Approach. PLoS One 2015; 10:e0134874. [PMID: 26274497 PMCID: PMC4537224 DOI: 10.1371/journal.pone.0134874] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 07/14/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Liver transplantation has received increased attention in the medical field since the 1980s following the introduction of new immunosuppressants and improved surgical techniques. Currently, transplantation is the treatment of choice for patients with end-stage liver disease, and it has been expanded for other indications. Liver transplantation outcomes depend on donor factors, operating conditions, and the disease stage of the recipient. A retrospective cohort was studied to identify mortality and graft failure rates and their associated factors. All adult liver transplants performed in the state of São Paulo, Brazil, between 2006 and 2012 were studied. METHODS AND FINDINGS A hierarchical Poisson multiple regression model was used to analyze factors related to mortality and graft failure in liver transplants. A total of 2,666 patients, 18 years or older, (1,482 males; 1,184 females) were investigated. Outcome variables included mortality and graft failure rates, which were grouped into a single binary variable called negative outcome rate. Additionally, donor clinical, laboratory, intensive care, and organ characteristics and recipient clinical data were analyzed. The mortality rate was 16.2 per 100 person-years (py) (95% CI: 15.1-17.3), and the graft failure rate was 1.8 per 100 py (95% CI: 1.5-2.2). Thus, the negative outcome rate was 18.0 per 100 py (95% CI: 16.9-19.2). The best risk model demonstrated that recipient creatinine ≥ 2.11 mg/dl [RR = 1.80 (95% CI: 1.56-2.08)], total bilirubin ≥ 2.11 mg/dl [RR = 1.48 (95% CI: 1.27-1.72)], Na+ ≥ 141.01 mg/dl [RR = 1.70 (95% CI: 1.47-1.97)], RNI ≥ 2.71 [RR = 1.64 (95% CI: 1.41-1.90)], body surface ≥ 1.98 [RR = 0.81 (95% CI: 0.68-0.97)] and donor age ≥ 54 years [RR = 1.28 (95% CI: 1.11-1.48)], male gender [RR = 1.19(95% CI: 1.03-1.37)], dobutamine use [RR = 0.54 (95% CI: 0.36-0.82)] and intubation ≥ 6 days [RR = 1.16 (95% CI: 1.10-1.34)] affected the negative outcome rate. CONCLUSIONS The current study confirms that both donor and recipient characteristics must be considered in post-transplant outcomes and prognostic scores. Our data demonstrated that recipient characteristics have a greater impact on post-transplant outcomes than donor characteristics. This new concept makes liver transplant teams to rethink about the limits in a MELD allocation system, with many teams competing with each other. The results suggest that although we have some concerns about the donors features, the recipient factors were heaviest predictors for bad outcomes.
Collapse
Affiliation(s)
- Luciana Haddad
- Digestive Transplant Unit—Gastroenterology Department, São Paulo University, São Paulo, Brazil
- * E-mail:
| | - Alex Jones Flores Cassenote
- Postgraduate Program in Infectious and Parasitic Diseases, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
- University of São Paulo, Faculty of Medicine, Center of Fuzzy Systems in Health, São Paulo, São Paulo, Brazil
| | - Wellington Andraus
- Digestive Transplant Unit—Gastroenterology Department, São Paulo University, São Paulo, Brazil
| | | | | | - Jair Minoro Abe
- Institute for Advanced Studies, University of São Paulo, São Paulo, Brazil
| | | |
Collapse
|
18
|
Dundar HZ, Yılmazlar T. Management of hepatorenal syndrome. World J Nephrol 2015; 4:277-286. [PMID: 25949942 PMCID: PMC4419138 DOI: 10.5527/wjn.v4.i2.277] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 12/29/2014] [Accepted: 02/02/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatorenal syndrome (HRS) is defined as development of renal dysfunction in patients with chronic liver diseases due to decreased effective arterial blood volume. It is the most severe complication of cirrhosis because of its very poor prognosis. In spite of several hypotheses and research, the pathogenesis of HRS is still poorly understood. The onset of HRS is a progressive process rather than a suddenly arising phenomenon. Since there are no specific tests for HRS diagnosis, it is diagnosed by the exclusion of other causes of acute kidney injury in cirrhotic patients. There are two types of HRS with different characteristics and prognostics. Type 1 HRS is characterized by a sudden onset acute renal failure and a rapid deterioration of other organ functions. It may develop spontaneously or be due to some precipitating factors. Type 2 HRS is characterized by slow and progressive worsening of renal functions due to cirrhosis and portal hypertension and it is accompanied by refractory ascites. The only definitive treatment for both Type 1 and Type 2 HRS is liver transplantation. The most suitable bridge treatment or treatment for patients who are not eligible for transplantation is a combination of terlipressin and albumin. For the same purpose, it is possible to try hemodialysis or renal replacement therapies in the form of continuous veno-venous hemofiltration. Artificial hepatic support systems are important for patients who do not respond to medical treatment. Transjugular intrahepatic portosystemic shunt may be considered as a treatment modality for unresponsive patients to medical treatment. The main goal of clinical surveillance in a cirrhotic patient is prevention of HRS before it develops. The aim of this article is to provide an updated review about the physiopathology of HRS and its treatment.
Collapse
|
19
|
Abstract
Renal impairment is common in liver disease and may occur as a consequence of the pathophysiological changes that underpin cirrhosis or secondary to a pre-existing unrelated insult. Nevertheless, the onset of renal impairment often portends a worsening prognosis. Hepatorenal syndrome remains one of the most recognized and reported causes of renal impairment in cirrhosis. However, other causes of renal impairment occur and can be classified into prerenal, intrinsic or postrenal, which are the subjects of the present review.
Collapse
|
20
|
Hoyer DP, Paul A, Gallinat A, Molmenti EP, Reinhardt R, Minor T, Saner FH, Canbay A, Treckmann JW, Sotiropoulos GC, Mathé Z. Donor information based prediction of early allograft dysfunction and outcome in liver transplantation. Liver Int 2015; 35:156-63. [PMID: 24351095 DOI: 10.1111/liv.12443] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 12/12/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Poor initial graft function was recently newly defined as early allograft dysfunction (EAD) [Olthoff KM, Kulik L, Samstein B, et al. Validation of a current definition of early allograft dysfunction in liver transplant recipients and analysis of risk factors. Liver Transpl 2010; 16: 943]. Aim of this analysis was to evaluate predictive donor information for development of EAD. METHODS Six hundred and seventy-eight consecutive adult patients (mean age 51.6 years; 60.3% men) who received a primary liver transplantation (LT) (09/2003-12/2011) were included. Standard donor data were correlated with EAD and outcome by univariable/multivariable logistic regression and Cox proportional hazards to identify prognostic donor factors after adjustment for recipient confounders. Estimates of relevant factors were utilized for construction of a new continuous risk index to develop EAD. RESULTS 38.7% patients developed EAD. 30-day survival of grafts with and without EAD was 59.8% and 89.7% (P < 0.0001). 30-day survival of patients with and without EAD was 68.5% and 93.1% (P < 0.0001) respectively. Donor body mass index (P = 0.0112), gGT (P = 0.0471), macrosteatosis (P = 0.0006) and cold ischaemia time (CIT) (P = 0.0031) were predictors of EAD. Internal cross validation showed a high predictive value (c-index = 0.622). CONCLUSIONS Early allograft dysfunction correlates with early results of LT and can be predicted by donor data only. The newly introduced risk index potentially optimizes individual decisions to accept/decline high risk organs. Outcome of these organs might be improved by shortening CIT.
Collapse
Affiliation(s)
- Dieter P Hoyer
- Department of General, Visceral and Transplantation Surgery, University Hospital, Essen, Germany
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Teng F, Wang GH, Tao YF, Guo WY, Wang ZX, Ding GS, Shi XM, Fu ZR. Criteria-specific long-term survival prediction model for hepatocellular carcinoma patients after liver transplantation. World J Gastroenterol 2014; 20:10900-10907. [PMID: 25152592 PMCID: PMC4138469 DOI: 10.3748/wjg.v20.i31.10900] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 03/06/2014] [Accepted: 05/14/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To establish a model to predict long-term survival of hepatocellular carcinoma (HCC) patients after liver transplantation (MHCAT).
METHODS: Two hundred and twenty-three patients with HCC were followed for at least six years to identify independent risk factors for long-term survival after liver transplantation (LT). The criteria for HCC liver transplantation included the Milan, University of California San Francisco, Hangzhou and Shanghai Fudan criteria. The Cox regression model was used to build MHCAT specifying these criteria. A survival analysis was carried out for patients with high or low risk.
RESULTS: The one-, three- and five-year cumulative survival of HCC patients after LT was 78.9%, 53.2% and 46.4%, respectively. Of the HCC patients, the proportion meeting the Hangzhou and Fudan criteria was significantly higher than the proportion meeting the Milan criteria (64.6% vs 39.5%, 52.0% vs 39.5%, P < 0.05). Moreover, the proportion meeting the Hangzhou criteria was also significantly higher than the proportion meeting other criteria (P < 0.01). Pre-operative alfa-fetoprotein level, intraoperative blood loss and retransplantation were common significant predictors of long-term survival in HCC patients with reference to the Milan, University of California San Francisco and Fudan criteria, whereas in MHCAT based on the Hangzhou criteria, total bilirubin, intraoperative blood loss and retransplantation were independent predictors. The c-statistic for MHCAT was 0.773-0.824, with no statistical difference among these four criteria. According to the MHCAT scoring system, patients with low risk showed a higher five-year survival than those with high risk (P < 0.001).
CONCLUSION: MHCAT can effectively predict long-term survival for HCC patients, but needs to be verified by multi-center retrospective or randomized controlled trials.
Collapse
|
22
|
Abstract
Liver transplantation represents an established component of the therapeutic repertoire for irreversible chronic liver diseases. Liver transplantation is confronted by a shortage of donor allografts as well as by an increasing overall number of potentially useful indications, which leads to a rationing of this therapeutic option. Since December 2006 the priority for liver transplantation is determined by the model for end-stage liver disease (MELD) and not by the length of waiting time. The evaluation of indications which are prioritized according to laboratory values (serum creatine, serum bilirubin and coagulation) and the so-called standard exception categories which have to fulfil specific criteria place increased demands on the interdisciplinary transplantation team, on the evaluation for liver transplantation and the prediction of the success of transplantation required by the Transplantation Act. The establishment and implementation of robust, objective and transparent systems to assess not only preoperative priorities but also postoperative benefits represents a major challenge for transplantation medicine.
Collapse
Affiliation(s)
- C P Strassburg
- Medizinischen Klinik und Poliklinik I, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland.
| |
Collapse
|
23
|
Neviere R, Edme JL, Montaigne D, Boleslawski E, Pruvot FR, Dharancy S. Prognostic implications of preoperative aerobic capacity and exercise oscillatory ventilation after liver transplantation. Am J Transplant 2014; 14:88-95. [PMID: 24354872 DOI: 10.1111/ajt.12502] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 08/09/2013] [Accepted: 09/09/2013] [Indexed: 01/25/2023]
Abstract
Our aim was to determine preoperative aerobic capacity (oxygen uptake [V'O2 ]) and prevalence of exercise oscillatory ventilation (EOV), underlying clinical characteristics of patients with EOV, and significance of reduced aerobic capacity and EOV in predicting mortality after liver transplantation. We prospectively studied 263 patients who underwent elective liver transplantation. Patients were followed up for 1 year. Despite minor impairment of resting cardiopulmonary function, preoperative aerobic capacity was reduced (peak V'O2 : 64 ± 19% predicted). EOV occurred in 10% of patients. Model for End-Stage Liver Disease score tended to be higher in patients with EOV compared to patients without, but failed to reach significance (p = 0.09). EOV patients had lower peak V'O2 and higher ventilatory drive. EOV was more frequent in nonsurvivors than in survivors (30% vs. 9%, p = 0.01) and was independently associated with posttransplant all-cause 1-year mortality. Reduced peak V'O2 best predicted the primary composite endpoint defined as 1-year mortality and/or prolonged hospitalization and early in-hospital mortality. Multivariate analysis revealed EOV (χ(2), 3.96; p = 0.04) and V'O2 (χ(2), 4.28; p = 0.04) as independent predictors of mortality and so-called primary composite endpoint, respectively. EOV and reduced peak V'O2 may identify high-risk candidates for liver transplantation, which would motivate a more aggressive treatment when detected.
Collapse
Affiliation(s)
- R Neviere
- Service d'Explorations Fonctionnelles Respiratoires EFR, Hopital Calmette, CHU Lille, France; Département de Physiologie EA4484, Université de Lille 2, Lille, France
| | | | | | | | | | | |
Collapse
|
24
|
Calmus Y. Prioritization of the cirrhotic patients entering intensive care unit for liver transplantation: Do we need to change the rules? Clin Res Hepatol Gastroenterol 2013; 37:437-8. [PMID: 23806626 DOI: 10.1016/j.clinre.2013.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 05/14/2013] [Indexed: 02/04/2023]
Affiliation(s)
- Yvon Calmus
- Centre de transplantation hépatique, hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France.
| |
Collapse
|
25
|
Hayashi H, Beppu T, Masuda T, Okabe H, Imai K, Hashimoto D, Ikuta Y, Chikamoto A, Watanabe M, Baba H. Large splenic volume may be a useful predictor for partial splenic embolization-induced liver functional improvement in cirrhotic patients. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:51-7. [PMID: 23798315 DOI: 10.1002/jhbp.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Partial splenic embolization (PSE) for cirrhotic patients has been reported not only to achieve an improvement in thrombocytopenia and portal hypertension, but also to induce PSE-associated fringe benefit such as individual liver functional improvement. The purpose of this study was to clarify the predictive marker of liver functional improvement due from PSE in cirrhotic patients. METHODS From April 1999 to January 2009, 83 cirrhotic patients with hypersplenism-induced thrombocytopenia (platelet count <10 × 10(4)/μl) underwent PSE. Of them, 71 patients with follow-up for more than one year after PSE were retrospectively investigated. RESULTS In liver tissues after PSE, proliferating cell nuclear antigen (PCNA)-positive hepatocytes were remarkably increased, speculating that PSE induced liver regenerative response. Indeed, serum albumin and cholinesterase levels increased to 104 ± 14% and 130 ± 65% each of the pretreatment level at one year after PSE. In a multiple linear regression analysis, preoperative splenic volume was extracted as the predictive factor for the improvement in cholinesterase level after PSE. Cirrhotic patients with preoperative splenic volume >600 ml obtained significantly higher serum albumin and cholinesterase levels at one year after PSE compared to those with less than 600 ml (P-values were 0.029 in both). CONCLUSION A large preoperative splenic volume was the useful predictive marker for an effective PSE-induced liver functional improvement.
Collapse
Affiliation(s)
- Hiromitsu Hayashi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Pascher A, Nebrig M, Neuhaus P. Irreversible liver failure: treatment by transplantation: part 3 of a series on liver cirrhosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:167-73. [PMID: 23533548 DOI: 10.3238/arztebl.2013.0167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 01/21/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver transplantation is the only established, causally directed treatment for irreversible chronic or acute liver failure. METHODS This review is based on papers retrieved by a selective search in the PubMed database, the index of randomized controlled trials of the European Society of Organ Transplantation, and the Cochrane database, along with an analysis of data from the authors' own center. RESULTS 1199 liver transplantations were performed in Germany in 2011. The most common indications were alcoholic cirrhosis (28%), cirrhosis of other causes (24%), and intrahepatic tumors (20%). Among recipients, the sex ratio was nearly 1:1 and the median age was just under 50. Across Europe, the 1-, 5-, and 10-year survival rates after liver transplantation were 82%, 71% and 61%. In our own center, the Charité in Berlin, the corresponding rates were 90.4%, 79.6% and 70.3%, based on an experience of 100 to 120 cases per year. The current rate of functioning transplants five years after liver transplantation is 52.6% in Germany and 66.2% internationally. Standard immunosuppression consists of a calcineurin inhibitor, tacrolimus or cyclosporine A, and steroids. Early complications include primary functional failure of the transplant, hemorrhage, thrombosis, acute rejection, and biliary complications. Over the long term, complications that can impair the outcome include chronic rejection, biliary strictures, cardiovascular and metabolic adverse effects, nephrotoxicity, neurotoxicity, and opportunistic infections and malignancies. CONCLUSION Liver transplantation is a successful and well-established form of treatment that is nonetheless endangered by a shortage of donor organs and other structural and organizational difficulties.
Collapse
Affiliation(s)
- Andreas Pascher
- Department of General, Visceral, and Transplant Surgery, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Germany.
| | | | | |
Collapse
|
27
|
Hummel R, Irmscher S, Schleicher C, Senninger N, Brockmann JG, Wolters HH. Aorto-hepatic bypass in liver transplantation in the MELD-era: outcomes after supraceliac and infrarenal bypasses. Surg Today 2013; 44:626-32. [DOI: 10.1007/s00595-013-0513-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 01/23/2013] [Indexed: 10/27/2022]
|
28
|
Wenger U, Neff TA, Oberkofler CE, Zimmermann M, Stehberger PA, Scherrer M, Schuepbach RA, Cottini SR, Steiger P, Béchir M. The relationship between preoperative creatinine clearance and outcomes for patients undergoing liver transplantation: a retrospective observational study. BMC Nephrol 2013; 14:37. [PMID: 23409777 PMCID: PMC3582487 DOI: 10.1186/1471-2369-14-37] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 02/13/2013] [Indexed: 12/24/2022] Open
Abstract
Background Renal failure with following continuous renal replacement therapy is a major clinical problem in liver transplant recipients, with reported incidences of 3% to 20%. Little is known about the significance of postoperative acute renal failure or acute-on-chronic renal failure to postoperative outcome in liver transplant recipients. Methods In this post hoc analysis we compared the mortality rates of 135 consecutive liver transplant recipients over 6 years in our center subject to their renal baseline conditions and postoperative RRT. We classified the patients into 4 groups, according to their preoperative calculated Cockcroft formula and the incidence of postoperative renal replacement therapy. Data then were analyzed in regard to mortality rates and in addition to pre- and peritransplant risk factors. Results There was a significant difference in ICU mortality (p=.008), hospital mortality (p=.002) and cumulative survival (p<.0001) between the groups. The highest mortality rate occurred in the group with RRT and normal baseline kidney function (20% ICU mortality, 26.6% hospital mortality and 50% cumulative 1-year mortality, respectively). The hazard ratio in this group was 9.6 (CI 3.2-28.6, p=.0001). Conclusion This study shows that in liver transplant recipient’s acute renal failure with postoperative RRT is associated with mortality and the mortality rate is higher than in patients with acute-on-chronic renal failure and postoperative renal replacement therapy.
Collapse
Affiliation(s)
- Urs Wenger
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, Zurich, CH 8091, Switzerland
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Weismüller TJ, Bleich F, Negm AA, Schneider A, Lankisch TO, Manns MP, Strassburg CP, Wedemeyer J. Screening colonoscopy in liver transplant candidates: risks and findings. Clin Transplant 2013; 27:E161-8. [PMID: 23383749 DOI: 10.1111/ctr.12083] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2012] [Indexed: 12/18/2022]
Abstract
The indication for mandatory screening colonoscopies in liver transplant candidates is controversial. Since the introduction of MELD-based allocation, patients with advanced liver disease and often severe comorbidities are prioritized for liver transplantation (LT). This study evaluated safety and outcome of colonoscopy in this high-risk patient group. During a two-yr period, we performed 243 colonoscopies in potential LT candidates. Endoscopic findings were registered in a standardized form, and correlations with biochemical or clinical parameters were analyzed using Mann-Whitney U-test and chi-square test. Only 57 patients (23.5%) had an endoscopically normal colon. Main findings were polyps (45.7%), hypertensive colopathy (24.3%), diverticulosis (21%), rectal varices (19.8%), and hemorrhoids (13.6%). In 21% of all patients, the removed polyps were diagnosed as adenomas. The prevalence of neoplastic polyps increased significantly with age: 13.6% (patients <50 yr) vs. 25% (patients ≥ 50 yr) (p = 0.03). Advanced neoplasia was found only in patients older than 40 yr. No major complications were observed; post-interventional hemorrhage was observed in 1.7% and controlled by clipping or injection therapy. In conclusion, lower gastrointestinal endoscopy is safe and effective in LT candidates. Due to the age dependency of neoplastic polyps, a screening colonoscopy should be performed in LT candidates older than 40 yr or with symptoms or additional risk factors.
Collapse
Affiliation(s)
- Tobias J Weismüller
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
30
|
The use of fatty liver grafts in modern allocation systems: risk assessment by the balance of risk (BAR) score. Ann Surg 2013; 256:861-8; discussion 868-9. [PMID: 23095632 DOI: 10.1097/sla.0b013e318272dea2] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To integrate the amount of hepatic steatosis in modern liver allocation models. BACKGROUND The aim of this study was to combine the 2 largest liver transplant databases (United States and Europe) in 1 comprehensive model to predict outcome after liver transplantation, with a novel focus on the impact of the presence of steatosis in the graft. METHODS We adjusted the balance of risk (BAR) score for its application to the European Liver Transplant Registry (ELTR) database containing 11,942 patients. All liver transplants from ELTR and United Network for Organ Sharing with recorded liver biopsies were then combined in one survival analysis in relation to the presence of graft micro- (n = 9,677) and macrosteatosis (n = 11,516). RESULTS Microsteatosis, regardless of the amount, was associated with a similar relationship between mortality and BAR score as nonsteatotic livers. Low-grade macrosteatotic liver grafts (≤30% macrosteatosis) resulted in 5-year graft-survival rates of 60% or more up to BAR 18, comparable to nonsteatotic grafts. However, use of moderate or severely steatotic liver grafts (>30% macrosteatosis) resulted in acceptable outcome only if the cumulative risk at transplant was low, that is, BAR score of 9 or less. CONCLUSIONS Microsteatotic or 30% or less macrosteatotic liver grafts can be used safely up to BAR score of 18 or less, but liver grafts with more than 30% macrosteatotis should be used with risk adjustment, that is, up to BAR score of 9 or less.
Collapse
|
31
|
Takeda H, Nishikawa H, Iguchi E, Ohara Y, Sakamoto A, Hatamaru K, Henmi S, Saito S, Nasu A, Komekado H, Kita R, Kimura T, Osaki Y. Impact of pretreatment serum cholinesterase level in unresectable advanced hepatocellular carcinoma patients treated with sorafenib. Mol Clin Oncol 2012; 1:241-248. [PMID: 24649154 DOI: 10.3892/mco.2012.48] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 11/16/2012] [Indexed: 12/18/2022] Open
Abstract
The value of serum cholinesterase (ChE) level as a predictive marker in sorafenib therapy for advanced hepatocellular carcinoma (HCC) has not yet been investigated. The present retrospective study therefore analyzed the impact of the serum ChE level in 93 patients with advanced HCC treated with sorafenib. Patients were categorized into two groups: group A with pretreatment serum ChE ≥140 IU/l (n=46) and group B with pretreatment serum ChE <140 IU/l (n=47). The correlation between clinicopathological findings, including serum ChE level, and overall survival (OS) and liver damage during sorafenib therapy was investigated. The median OS of the patients was 275 days, while OS was markedly higher in group A compared to group B (P=0.002). In 70 Child-Pugh A patients, serum ChE level was a significant prognostic predictor in multivariate analysis [P=0.019, hazard ratio (HR) =2.612; 95% confidence interval (CI), 1.174-5.810]. During sorafenib treatment, 22 patients developed liver dysfunction of grade 3 or higher. Only two group A patients (4.3%) developed liver dysfunction, compared to 20 group B patients (42.6%) (P<0.001). Multivariate analysis demonstrated that the pretreatment serum ChE level was the strongest predictor of liver damage (P=0.002, HR=0.061, 95% CI: 0.010-0.373), indicating serum ChE <140 IU/l to be the only independent predictor associated with severe liver function damage during sorafenib treatment in 70 patients with grade A Child-Pugh (P= 0.016; HR= 0.122; 95% CI, 0.022-0.676). In conclusion, lower serum ChE level is a significant predictor of poor prognosis and severe liver damage in HCC patients treated with sorafenib. Advanced HCC patients with lower serum ChE levels, including those with a Child-Pugh A pretreatment liver function score, should be given sorafenib therapy with caution.
Collapse
Affiliation(s)
- Haruhiko Takeda
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hiroki Nishikawa
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Eriko Iguchi
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yoshiaki Ohara
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Azusa Sakamoto
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Keiichi Hatamaru
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Shinichiro Henmi
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Sumio Saito
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Akihiro Nasu
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hideyuki Komekado
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Ryuichi Kita
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Toru Kimura
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yukio Osaki
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| |
Collapse
|
32
|
Dillmann J, Popp FC, Fillenberg B, Zeman F, Eggenhofer E, Farkas S, Scherer MN, Koller M, Geissler EK, Deans R, Ladenheim D, Loss M, Schlitt HJ, Dahlke MH. Treatment-emergent adverse events after infusion of adherent stem cells: the MiSOT-I score for solid organ transplantation. Trials 2012; 13:211. [PMID: 23151227 PMCID: PMC3543274 DOI: 10.1186/1745-6215-13-211] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 10/31/2012] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Cellular therapy after organ transplantation is emerging as an intriguing strategy to achieve dose reduction of classical immunosuppressive pharmacotherapy. Here, we introduce a new scoring system to assess treatment-emergent adverse events (TEAEs) of adherent stem cell therapies in the clinical setting of allogeneic liver transplantation (for example, the MiSOT-I trial Eudract CT: 2009-017795-25). METHODS The score consists of three independent modalities (set of parameters) that focus on clinically relevant events early after intravenous or intraportal stem cell infusion: pulmonary toxicity, intraportal-infusional toxicity and systemic toxicity. For each modality, values between 0 (no TEAE) and 3 (severe TEAE) were defined. The score was validated retrospectively on a cohort of n=187 recipients of liver allografts not receiving investigational cell therapy between July 2004 and December 2010. These patients represent a control population for further trials. Score values were calculated for days 1, 4, and 10 after liver transplantation. RESULTS Grade 3 events were most commonly related to the pulmonary system (3.5% of study cohort on day 4). Almost no systemic-related TEAEs were observed during the study period. The relative frequency of grade 3 events never exceeded 5% over all modalities and time points. A subgroup analysis for grade 3 patients provided no descriptors associated with severe TEAEs. CONCLUSION The MiSOT-I score provides an assessment tool to score specific adverse events that may occur after adherent stem cell therapy in the clinical setting of organ transplantation and is thus a helpful tool to conduct a safety study.
Collapse
Affiliation(s)
- Johannes Dillmann
- Department of Surgery, University Hospital Regensburg, Franz Josef Strauss Allee 11, 93053, Regensburg, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Seehofer D, Nebrig M, Denecke T, Kroencke T, Weichert W, Stockmann M, Somasundaram R, Schott E, Puhl G, Neuhaus P. Impact of neoadjuvant transarterial chemoembolization on tumor recurrence and patient survival after liver transplantation for hepatocellular carcinoma: a retrospective analysis. Clin Transplant 2012; 26:764-74. [PMID: 22432589 DOI: 10.1111/j.1399-0012.2012.01609.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2012] [Indexed: 12/13/2022]
Abstract
Transarterial chemoembolization (TACE) has gained wide acceptance as a bridge to liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Aim of this analysis was to compare long-term results with and without neoadjuvant TACE and to identify subgroups, which particularly benefit from TACE. Patients with HCC transplanted at our center were retrospectively analyzed. The following were excluded to increase consistency: incidental-HCC, Child-C, living-related-LT, other HCC-specific-treatment. Of 336 patients, 177 were subject of this analysis, 71 received TACE and 106 no HCC therapy. Patients with and without TACE showed similar five-yr survival (73/67%) and recurrence rates (23/29%). Progression on the waiting list was associated with a higher recurrence rate in the TACE (50 vs.12%) and the non-TACE group (40 vs. 22%). HCC recurrence was reduced in patients inside Milan (0.053) and UCSF (0.037) criteria by neoadjuvant TACE but not outside UCSF (0.99). Also a trend towards an improved survival was seen within these criteria. Our large single center experience suggests that TACE lowers the HCC recurrence rate in patients inside the Milan and UCSF criteria. Moreover, the response to TACE is a good indicator of low recurrence rates. The effect of TACE might be more pronounced in patients with longer waiting time than in this cohort (mean, 4.6 months).
Collapse
Affiliation(s)
- Daniel Seehofer
- Department of General-, Visceral and Transplantation Surgery, Charité Campus Virchow, Berlin, Germany.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Are there better guidelines for allocation in liver transplantation? A novel score targeting justice and utility in the model for end-stage liver disease era. Ann Surg 2012; 254:745-53; discussion 753. [PMID: 22042468 DOI: 10.1097/sla.0b013e3182365081] [Citation(s) in RCA: 309] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To design a new score on risk assessment for orthotopic liver transplantation (OLT) based on both donor and recipient parameters. BACKGROUND The balance of waiting list mortality and posttransplant outcome remains a difficult task in the era of the model for end-stage liver disease (MELD). METHODS Using the United Network for Organ Sharing database, a risk analysis was performed in adult recipients of OLT in the United States of America between 2002 and 2010 (n = 37,255). Living donor-, partial-, or combined-, and donation after cardiac death liver transplants were excluded. Next, a risk score was calculated (balance of risk score, BAR score) on the basis of logistic regression factors, and validated using our own OLT database (n = 233). Finally, the new score was compared with other prediction systems including donor risk index, survival outcome following liver transplantation, donor-age combined with MELD, and MELD score alone. RESULTS Six strongest predictors of posttransplant survival were identified: recipient MELD score, cold ischemia time, recipient age, donor age, previous OLT, and life support dependence prior to transplant. The new balance of risk score stratified recipients best in terms of patient survival in the United Network for Organ Sharing data, as in our European population. CONCLUSIONS The BAR system provides a new, simple and reliable tool to detect unfavorable combinations of donor and recipient factors, and is readily available before decision making of accepting or not an organ for a specific recipient. This score may offer great potential for better justice and utility, as it revealed to be superior to recent developed other prediction scores.
Collapse
|
35
|
Experience Since MELD Implementation: How Does the New System Deliver? Int J Hepatol 2012; 2012:264015. [PMID: 23091734 PMCID: PMC3467768 DOI: 10.1155/2012/264015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 09/03/2012] [Accepted: 09/03/2012] [Indexed: 12/12/2022] Open
Abstract
Because of increasing waiting-list mortality, the MELD (Model for End-Stage Liver Disease) allocation system was implemented within most countries of the Eurotransplant area on December 16, 2006. Five years have now passed, and we review in this paper the effects of the MELD-based allocation upon the waiting list for liver transplantation, on peri-operative management and on postoperative outcome. Giving priority to sicker patients on the waiting list has resulted in a significant increase in mean MELD score at the time of organ allocation. Consequently, there has also been a significant reduction in waiting-list mortality. However, in Germany a worsening in postoperative outcome, mainly in the group of high-MELD recipients (≥30 points), has been reported. This paper presents comprehensive results following liver transplantation within the MELD era. Especially for the group of high-risk recipients, risk factors for impaired survival are presented and discussed.
Collapse
|
36
|
Weismüller TJ, Kirchner GI, Scherer MN, Negm AA, Schnitzbauer AA, Lehner F, Klempnauer J, Schlitt HJ, Manns MP, Strassburg CP. Serum ferritin concentration and transferrin saturation before liver transplantation predict decreased long-term recipient survival. Hepatology 2011; 54:2114-24. [PMID: 21898488 DOI: 10.1002/hep.24635] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
UNLABELLED Serum ferritin (SF) concentration is a widely available parameter used to assess iron homeostasis. It has been described as a marker to identify high-risk patients awaiting liver transplantation (LT) but is also elevated in systemic immune-mediated diseases, metabolic syndrome, and in hemodialysis where it is associated with an inferior prognosis. This study analyzed whether SF is not only a predictor of liver-related mortality prior to LT but also an independent marker of survival following LT. In a dual-center, retrospective study, a cohort of 328 consecutive first-LT patients from Hannover Medical School, Germany (2003-2008, follow-up 1260 days), and 82 consecutive LT patients from Regensburg University Hospital, Germany (2003-2007, follow-up 1355 days) as validation cohort were analyzed. In patients exhibiting SF ≥365 μg/L versus <365 μg/L prior to LT, 1-, 3-, and 5-year post-LT survival was 73.3% versus 81.1%, 64.4% versus 77.3%, and 61.1% versus 74.4%, respectively (overall survival P = 0.0097), which was confirmed in the validation cohort (overall survival of 55% versus 83.3%, P = 0.005). Multivariate analyses identified SF ≥365 μg/L combined with transferrin saturation (TFS) <55%, hepatocellular carcinoma, and the survival after LT (SALT) score as independent risk factors for death. In patients with SF concentrations ≥365 μg/L and TFS <55%, overall survival was 54% versus 74.8% in the remaining group (P = 0.003). In the validation cohort, it was 28.6% versus 72% (P = 0.017), respectively. CONCLUSION SF concentration ≥365 μg/L in combination with TFS <55% before LT is an independent risk factor for mortality following LT. Lower TFS combined with elevated SF concentrations indicate that acute phase mechanisms beyond iron overload may play a prognostic role. SF concentration therefore not only predicts pre-LT mortality but also death following LT.
Collapse
Affiliation(s)
- Tobias J Weismüller
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Abstract
The development of hepatorenal syndrome (HRS) is related to many changes associated with advanced cirrhosis. Because vasoconstrictors correct systemic and splanchnic hemodynamic abnormalities, they are effective treatments for HRS, although only in approximately 40% of HRS patients. Emerging data show that combination treatment with vasoconstrictors and TIPS may yield better outcomes than either alone. All HRS patients should be assessed for liver transplantation. Reversing HRS before transplantation is associated with better long-term survival. Combined liver– kidney transplantation is indicated for those with irreversible kidney injury. Otherwise, there is some merit in performing a liver transplant first and only considering a kidney transplant later.
Collapse
Affiliation(s)
- Wesley Leung
- Division of Gastroenterology, Department of Medicine, 9N/983, Toronto General Hospital, University of Toronto, 200 Elizabeth Street, Toronto, Ontario M5G2C4, Canada
| | | |
Collapse
|
38
|
Benckert C, Quante M, Thelen A, Bartels M, Laudi S, Berg T, Kaisers U, Jonas S. Impact of the MELD allocation after its implementation in liver transplantation. Scand J Gastroenterol 2011; 46:941-8. [PMID: 21443420 DOI: 10.3109/00365521.2011.568521] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE On 16 December 2006, most Eurotransplant countries changed waiting time oriented liver allocation policy to the urgency oriented Model for End-stage Liver Disease (MELD) system. There are limited data on the effects of this policy change within the Eurotransplant community. PATIENTS AND METHODS A total of 154 patients who had undergone deceased donor liver transplantation (LT) were retrospectively analyzed in three time periods: period A (1-year pre-MELD, n = 42) versus period B (1-year post-MELD, n = 52) versus period C (2 years after MELD implementation, n = 60). RESULTS The median MELD score at the time of LT increased from 16.3 points in period A to 22.4 and 20.4 in periods B and C, respectively (p = 0.007). Waitlist mortality decreased from 18.4% in period A to 10.4% and 9.4% in periods B and C, respectively (p = 0.015). Three-month mortality did not change significantly (10% each for periods A, B and C). One-year survival was 84% for the MELD 6-19 group compared with 81% in the MELD 20-29 group and 74% in the MELD ≥30 group (p = 0.823). Analyzing MELD score and previously described prognostic scores [i.e. survival after liver transplantation (SALT) score and donor-MELD (D-MELD) score] with regard to 1-year survival, only a high risk SALT score was predictive (p = 0.038). In our center, 2 years after implementation of the MELD system, waitlist mortality decreased, while 90-day mortality did not change significantly. CONCLUSION Up to now, only the SALT score proved to be of prognostic relevance post-transplant.
Collapse
Affiliation(s)
- Christoph Benckert
- Department of Visceral, Transplantation, Thoracic and Vascular Surgery, Universitätsklinikum Leipzig, Leipzig, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Vrochides D, Hassanain M, Barkun J, Tchervenkov J, Paraskevas S, Chaudhury P, Cantarovich M, Deschenes M, Wong P, Ghali P, Chan G, Metrakos P. Association of preoperative parameters with postoperative mortality and long-term survival after liver transplantation. Can J Surg 2011; 54:101-6. [PMID: 21443827 DOI: 10.1503/cjs.035909] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The ability of Child-Turcotte-Pugh (CTP) or Model for End-Stage Liver Disease (MELD) scores to predict recipient survival after liver transplantation is controversial. This analysis aims to identify preoperative parameters that might be associated with early postoperative mortality and long-term survival after liver transplantation. METHODS We studied a total of 15 parameters, using both univariate and multivariate models, among adults who underwent primary liver transplantation. RESULTS A total of 458 primary adult liver transplants were performed. Fifty-seven (12.44%) patients died during the first 3 postoperative months and composed the early mortality group. The remaining 401 patients composed the long-term patient survival group. The parameters that were identified through univariate analysis to be associated with early postoperative mortality were CTP score, MELD score, bilirubin, creatinine, international normalized ratio and warm ischemia time (WIT). In all multivariate models, WIT retained its statistical significance. The 10-year long-term survival was 65%. The parameters that were identified to be independent predictors of long-term survival were the recipient's sex (improved survival in women, p = 0.005), diagnosis of hepatocellular cancer (p=0.015) and recipient's age (p=0.024). CONCLUSION Either CTP or MELD score, in conjunction with WIT, might have a role in predicting early postoperative mortality after liver transplantation, whereas the recipient's sex and the absence of hepatocellular cancer are associated with improved long-term survival.
Collapse
Affiliation(s)
- Dionisios Vrochides
- Department of Surgery and the Multi-Organ Transplant Program, McGill University, Montréal, Que., Canada.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Sussman AN, Boyer TD. Management of refractory ascites and hepatorenal syndrome. Curr Gastroenterol Rep 2011; 13:17-25. [PMID: 21080246 DOI: 10.1007/s11894-010-0156-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
One of the most common manifestations of the development of portal hypertension in the patient with cirrhosis is the appearance of ascites. Once ascites develops, the prognosis worsens and the patient becomes susceptible to complications such as bacterial peritonitis, hepatic hydrothorax, hyponatremia, and complications of diuretic therapy. As the liver disease progresses, the ascites becomes more difficult to treat and many patients develop renal failure. Most patients can be managed by diuretics which, when used correctly, will control the ascites. Spontaneous bacterial peritonitis can be treated effectively, but portends a worse prognosis. Once the ascites becomes refractory to diuretics, liver transplantation is the best option, although use of transjugular intrahepatic portosystemic shunts will control the ascites in many patients. Lastly, the development of hepatorenal syndrome indicates the patient's liver disease is advanced, and transplantation again is the best option. However, use of vasoconstrictors may improve renal function in some patients, helping in their management while they await a liver transplant.
Collapse
Affiliation(s)
- Amy N Sussman
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | | |
Collapse
|
41
|
Yong CM, Sharma M, Ochoa V, Abnousi F, Roberts J, Bass NM, Niemann CU, Shiboski S, Prasad M, Tavakol M, Ports TA, Gregoratos G, Yeghiazarians Y, Boyle AJ. Multivessel coronary artery disease predicts mortality, length of stay, and pressor requirements after liver transplantation. Liver Transpl 2010; 16:1242-8. [PMID: 21031539 DOI: 10.1002/lt.22152] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The optimal preoperative cardiac evaluation strategy for patients with end-stage liver disease (ESLD) undergoing liver transplantation remains unknown. Patients are frequently referred for cardiac catheterization, but the effects of coronary artery disease (CAD) on posttransplant mortality are also unknown. We sought to determine the contribution of CAD and multivessel CAD in particular to posttransplant mortality. We performed a retrospective study of ESLD patients undergoing cardiac catheterization before liver transplant surgery between August 1, 2004 and August 1, 2007 to determine the effects of CAD on outcomes after transplantation. Among 83 patients who underwent left heart catheterization, 47 underwent liver transplantation during the follow-up period. Twenty-one of all ESLD patients who underwent liver transplantation (45%) had CAD. Fifteen of the transplant patients with CAD (71%) had multivessel disease. Among transplant patients, the presence of multivessel CAD (versus no CAD) was predictive of mortality (27% versus 4%, P = 0.046), increased length of stay (22 versus 15 days, P = 0.050), and postoperative pressor requirements (27% versus 4%, P = 0.029). Interestingly, neither the presence of any CAD nor the severity of stenosis in any single coronary artery predicted mortality. Furthermore, none of the traditional clinical predictors (age, gender, diabetes, creatinine, ejection fraction, and Model for End-Stage Liver Disease score) were predictive of mortality among transplant recipients. In conclusion, multivessel CAD is associated with higher mortality after liver transplantation when it is documented angiographically before transplantation, even in the absence of severe coronary artery stenosis. This study provides preliminary evidence showing that there may be significant prognostic value in coronary angiography as a part of the pretransplant workup.
Collapse
Affiliation(s)
- Celina M Yong
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Benckert C, Quante M, Jonas S. [Allocation problems in organ transplantation: practical medical experience]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2010; 104:397-9. [PMID: 20870490 DOI: 10.1016/j.zefq.2010.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Solid organ transplantation is one the most successful medical innovations of the 20th century. Due to an increasing number of patients on the waiting lists for transplantation in the context of persisting organ shortage the aim of optimal allocation policy is the best possible balance between medical urgency and postoperative outcome. Because of scientific evolution and increasing waiting list mortality the allocation system for liver transplantation was altered in December 2006. As intended, the preferential treatment of sicker patients resulted in a reduced waiting list mortality. On the other hand, an unintentional decrease in postoperative survival was observed. This obvious imbalance between medical urgency and postoperative outcome has led to the current allocation problem. Several scientific approaches for optimising allocation policy will be presented and discussed in this paper. Finally, continuous review and adaptation will be a persisting challenge for people working in the field of solid organ transplantation.
Collapse
Affiliation(s)
- Christoph Benckert
- Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie; Universitätsklinikum Leipzig, Leipzig.
| | | | | |
Collapse
|
43
|
Hwang WJ, Jeon JP, Kang SH, Chung HS, Kim JY, Park CS. Sluggish decline in a post-transplant model for end-stage liver disease score is a predictor of mortality in living donor liver transplantation. Korean J Anesthesiol 2010; 59:160-6. [PMID: 20877699 PMCID: PMC2946032 DOI: 10.4097/kjae.2010.59.3.160] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Revised: 05/14/2010] [Accepted: 06/04/2010] [Indexed: 12/13/2022] Open
Abstract
Background The pre-transplant model for end-stage liver disease (pre-MELD) score is controversial regarding its ability to predict patient mortality after liver transplantation (LT). Prominent changes in physical conditions through the surgery may require a post-transplant indicator for better mortality prediction. We aimed to investigate whether the post-transplant MELD (post-MELD) score can be a predictor of 1-year mortality. Methods Perioperative variables of 269 patients with living donor LT were retrospectively investigated on their association with 1-year mortality. Post-MELD scores until the 30th day and their respective declines from the 1st day post-MELD score were included along with pre-MELD, acute physiology and chronic health evaluation (APACHE) II, and sequential organ failure assessment (SOFA) scores on the 1st post-transplant day. The predictive model of mortality was established by multivariate Cox's proportional hazards regression. Results The 1-year mortality rate was 17% (n = 44), and the leading cause of death was graft failure. Among prognostic indicators, only post-MELD scores after the 5th day and declines in post-MELD scores until the 5th and 30th day were associated with mortality in univariate analyses (P < 0.05). After multivariate analyses, declines in post-MELD scores until the 5th day of less than 5 points (hazard ratio 2.35, P = 0.007) and prolonged mechanical ventilation ≥24 hours were the earliest independent predictors of 1-year mortality. Conclusions A sluggish decline in post-MELD scores during the early post-transplant period may be a meaningful prognostic indicator of 1-year mortality after LT.
Collapse
Affiliation(s)
- Won Jung Hwang
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | | | | | | | | | | |
Collapse
|
44
|
Weismüller TJ, Fikatas P, Schmidt J, Barreiros AP, Otto G, Beckebaum S, Paul A, Scherer MN, Schmidt HH, Schlitt HJ, Neuhaus P, Klempnauer J, Pratschke J, Manns MP, Strassburg CP. Multicentric evaluation of model for end-stage liver disease-based allocation and survival after liver transplantation in Germany--limitations of the 'sickest first'-concept. Transpl Int 2010; 24:91-9. [PMID: 20819196 DOI: 10.1111/j.1432-2277.2010.01161.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Since the introduction of model for end-stage liver disease (MELD) in 2006, post-orthotopic liver transplantation (OLT) survival in Germany has declined. The aim of this study was to evaluate risk factors and prognostic scores for outcome. All adult OLT recipients in seven German transplant centers after MELD implementation (December 2006-December 2007) were included. Recipient data were analyzed for their influence on 1-year outcome. A total of 462 patients (mean calculated MELD = 20.5, follow-up: 1 year) were transplanted for alcoholic cirrhosis (33.1%), hepatocellular carcinoma (26.6%), Hepatitis-C (17.1%), Hepatitis-B (9.5%), primary sclerosing cholangitis (5.6%) and late graft-failure after first OLT before December 2006 (8.7%). 1-year patient survival was 75.8% (graft survival 71.2%) correlating with MELD parameters and serum choline esterase. MELD score >30 [odds ratio (OR) = 4.17, confidence interval: 2.57-6.78, 12-month survival = 52.6%, c-statistic = 0.669], hyponatremia (OR = 2.07), and pre-OLT hemodialysis (OR = 2.35) were the main death risk factors. In alcoholic cirrhosis (n = 153, mean MELD = 21.1) and hepatocellular carcinoma (n = 123, mean MELD = 13.5), serum bilirubin and the survival after liver transplantation score were independent outcome parameters, respectively. MELD >30 currently represents a major risk factor for outcome. Risk factors differ in individual patient subgroups. In the current German practice of organ allocation to sicker patients, outcome prediction should be considered to prevent results below acceptable standards.
Collapse
Affiliation(s)
- Tobias J Weismüller
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Current world literature. Curr Opin Anaesthesiol 2010; 23:283-93. [PMID: 20404787 DOI: 10.1097/aco.0b013e328337578e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
46
|
Renal failure in patients with cirrhosis: hepatorenal syndrome and renal support strategies. Curr Opin Anaesthesiol 2010; 23:139-44. [PMID: 20124895 DOI: 10.1097/aco.0b013e32833724a8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The development of hepatorenal syndrome in liver cirrhosis leads to an increased morbidity and mortality in patients with cirrhosis. Currently, there are no proven methods for the treatment or prevention of hepatorenal syndrome except to maintain adequate hemodynamics and intravascular volume in this patient population. These patients will frequently require renal replacement therapy when presenting for hepatic transplantation. RECENT FINDINGS New consensus definitions have been published in order to create uniform standards for classifying and diagnosing acute kidney injury. Two such groups are the Acute Dialysis Quality Initiative (ADQI) and the Acute Kidney Injury Network (AKIN), which have proposed approaches to defining criteria for acute kidney injury. Recent literature supports not only the role of splanchnic vasodilation and systemic vasoconstriction but also heart failure in the pathogenesis of hepatorenal syndrome. The practice of using vasoconstrictor and intravenous albumin therapy for the treatment of hepatorenal syndrome is ongoing with a growing body of recent data supporting the use of vasopressin analogs as the first-line therapy in the ICU setting with knowledge of the possible cardiovascular side-effects. SUMMARY Hepatorenal syndrome, HRS, is a diagnosis of exclusion. There are two forms of hepatorenal syndrome: type 1 hepatorenal syndrome and type 2 hepatorenal syndrome. Type 1 HRS is rapidly progressive and portends a very poor prognosis and has a high mortality rate. Type 2 is more indolent while still associated with an overall poor prognosis. Treatment of HRS is largely still supportive. It is imperative to maintain euvolemia and hemodynamics in this patient population to optimize renal perfusion and preserve renal function. Renal replacement therapy may be necessary in this chronically ill patient population, if renal function deteriorates such that the kidneys cannot maintain metabolic and volume homeostasis. Further research is still necessary as to the prevention and effective treatment for hepatorenal syndrome.
Collapse
|
47
|
Oberkofler CE, Dutkowski P, Stocker R, Schuepbach RA, Stover JF, Clavien PA, Béchir M. Model of end stage liver disease (MELD) score greater than 23 predicts length of stay in the ICU but not mortality in liver transplant recipients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R117. [PMID: 20550662 PMCID: PMC2911764 DOI: 10.1186/cc9068] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 04/30/2010] [Accepted: 06/15/2010] [Indexed: 02/06/2023]
Abstract
Introduction The impact of model of end stage liver disease (MELD) score on postoperative morbidity and mortality is still elusive, especially for high MELD. There are reports of poorer patient outcome in transplant candidates with high MELD score, others though report no influence of MELD score on outcome and survival. Methods We retrospectively analyzed data of 144 consecutive liver transplant recipients over a 72-month period in our transplant unit, from January 2003 until December 2008 and performed uni- and multivariate analysis for morbidity and mortality, in particular to define the influence of MELD to these parameters. Results This study identified MELD score greater than 23 as an independent risk factor of morbidity represented by intensive care unit (ICU) stay longer than 10 days (odds ratio 7.0) but in contrast had no negative impact on mortality. Furthermore, we identified transfusion of more than 7 units of red blood cells as independent risk factor for mortality (hazard ratio 7.6) and for prolonged ICU stay (odds ratio [OR] 7.8) together with transfusion of more than 10 units of fresh frozen plasma (OR 11.6). Postoperative renal failure is a strong predictor of morbidity (OR 7.9) and postoperative renal replacement therapy was highly associated with increased mortality (hazard ratio 6.8), as was hepato renal syndrome prior to transplantation (hazard ratio 13.2). Conclusions This study identified MELD score greater than 23 as an independent risk factor of morbidity represented by ICU stay longer than 10 days but in contrast had no negative impact on mortality. This finding supports the transplantation of patients with high MELD score but only with knowledge of increased morbidity.
Collapse
Affiliation(s)
- Christian E Oberkofler
- Department of Visceral- and Transplantation Surgery, University Hospital of Zurich, Raemistrasse 100, Zürich 8091, Switzerland.
| | | | | | | | | | | | | |
Collapse
|
48
|
Rymarz A, Serwacki M, Rutkowski M, Pakosiński K, Grodzicki M, Patkowski W, Kacka A, Ołdakowska-Jedynak U, Krawczyk M. Prevalence and predictors of acute renal injury in liver transplant recipients. Transplant Proc 2010; 41:3123-5. [PMID: 19857692 DOI: 10.1016/j.transproceed.2009.08.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Renal failure is a major factor impacting liver transplant outcomes. Renal functional impairment predicts decreased survival, leading to increased morbidity and mortality. The aim of this study was to estimate the incidence, risk factors, and resolution of acute kidney injury (AKI) among liver transplant recipients during the operative hospital stay. We analyzed data from 99 orthotopic liver transplantations (OLT) performed at our center in 2008. Posttransplantation occurrence of AKI was defined as an increase in serum creatinine (SCr) concentration of 0.3 mg/dL or more, namely, 1.5-fold from baseline. AKI was observed among 31.31% of liver transplant recipients (n = 31). The mean increase in SCr was 2.49 +/- 0.78-fold from baseline. The mean posttransplant SCr level was 2.59 +/- 0.92 mg/dL. Renal replacement therapy was introduced to 16.12% (n = 5) liver recipients developing AKI. Among them, 2 subjects (6.45%) died. The mean SCr level at the time of discharge from the hospital was 1.17 +/- 0.57 mg/dL among the AKI group compared with 0.77 +/- 0.32 mg/dL among the group without AKI. Pretransplant renal impairment expressed by an elevated SCr concentration (relative risk [RR] = 1.25; P = .0386) and treatment with exogenous vasoconstrictors during the operation (RR = 2.27; P = .016) were identified as risk factors for developing AKI after liver transplantation.
Collapse
Affiliation(s)
- A Rymarz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 1a Banacha St, Warsaw, Poland.
| | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Charlton MR, Wall WJ, Ojo AO, Ginès P, Textor S, Shihab FS, Marotta P, Cantarovich M, Eason JD, Wiesner RH, Ramsay MA, Garcia-Valdecasas JC, Neuberger JM, Feng S, Davis CL, Gonwa TA. Report of the first international liver transplantation society expert panel consensus conference on renal insufficiency in liver transplantation. Liver Transpl 2009; 15:S1-34. [PMID: 19877213 DOI: 10.1002/lt.21877] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
50
|
Seehofer D, Thelen A, Neumann UP, Veltzke-Schlieker W, Denecke T, Kamphues C, Pratschke J, Jonas S, Neuhaus P. Extended bile duct resection and [corrected] liver and transplantation in patients with hilar cholangiocarcinoma: long-term results. Liver Transpl 2009; 15:1499-507. [PMID: 19877250 DOI: 10.1002/lt.21887] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
For patients with irresectable hilar cholangiocarcinoma, liver transplantation (LT) is currently being reassessed because of promising data for neoadjuvant radiochemotherapy. For increased radicality, hepatectomy in combination with pancreatic head resection [extended bile duct resection (EBDR)] was performed for irresectable hilar cholangiocarcinoma during our initial experience. EBDR and LT was performed in 16 patients between 1992 and 1998. No neoadjuvant or adjuvant treatment was performed. The Union Internationale Contre le Cancer stages were I (n = 6), IIA (5), IIB (3), and IV (2). To evaluate the suspected increase in surgical radicality, a matched pair analysis was performed with 8 patients undergoing LT for hilar cholangiocarcinoma without partial pancreatoduodenectomy. The 1-, 5-, and 10-year patient survival rates after EBDR were 63%, 38%, and 38%, respectively. Twelve patients died: 2 died because of postoperative complications, 8 died because of tumor recurrence, and 2 died while recurrence-free more than 10 years after transplantation. Among the 6 stage I patients, only 1 developed tumor recurrence, but 2 died because of postoperative complications. The following factors showed a trend toward inferior survival: distant metastases, positive lymph nodes, high carbohydrate antigen 19-9 levels, and preoperative percutaneous transhepatic cholangiodrainage. When all lymph node-negative patients were considered after the exclusion of perioperative deaths, 10-year survival was 56%. In conclusion, the overall long-term survival was relatively low in our inhomogeneous cohort but favorable in patients without metastases. However, because of the increased perioperative mortality, EBDR is not recommended as a standard procedure for hilar cholangiocarcinoma instead of LT alone. To further improve the results, other approaches such as (neo)adjuvant therapy have to be increasingly investigated.
Collapse
Affiliation(s)
- Daniel Seehofer
- Department of General, Visceral, and Transplant Surgery, Charité Campus Virchow, Berlin, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|