Core outcome sets and benchmarking complications: Defining best practices for standardized outcome reporting in liver transplantation

Mastering the narrative: Precision reporting of risk and outcomes in liver transplantation

Liver transplantation is associated with a high risk of postoperative complications due to the complexity of the surgical procedure, recipient disease severity and the wide range of graft quality, which remains somewhat unpredictable. However, survival rates after transplantation continue to improve and the focus has thus turned to other clinically relevant endpoints including post-transplant complications, patient quality of life and costs. Procedures like liver transplantation offer the entire spectrum of post-surgical events, even in donor-recipient constellations deemed of low risk within recently defined benchmark criteria. The Clavien-Dindo classification and the CCI (comprehensive complication index) were established to assess postoperative morbidity and are widely utilised across surgical specialties. These scores depend on the number and grade of complications, which reflect the interventions required, and are frequently used to assess specific donor-recipient risk profiles and new approaches, such as machine perfusion. However, these scores are associated with inter-observer variability when used in practice, mainly due to the lack of uniform definitions. The concept of benchmarking was recently introduced in surgery and transplantation as a mechanism of standardising expected donor/recipient risk with outcomes within the first year after surgery. However, the management of complications differs significantly worldwide, as does the rating scale assigned to various complications. This may lead to inhomogeneous interpretation of study results, leading to difficulty in assessing the clinical effects of novel preservation technologies and other therapeutics in liver transplantation. This article critically discusses frequent challenges associated with risk and outcome assessment following liver transplantation.

Microbiota-directed intervention in living donor liver transplant recipients: protocol for a randomised double-blind placebo-controlled trial

INTRODUCTION

Acute-on-chronic liver failure (ACLF) patients have the highest propensity for post-liver transplantation (LT) infections and mortality. Liver-associated diseases have been one of the primary targets for synbiotic therapy to augment immunity and mitigate infections. However, despite multiple studies showing benefits of synbiotics in liver diseases, data on their use following LT are sparse.

METHODS AND ANALYSIS

This randomised placebo-controlled study aims to assess the impact of synbiotics in ACLF patients undergoing living donor liver transplantation (LDLT). Following randomisation by computer-generated block number sequence, 3 days prior to LDLT, the intervention arm will receive standard medical treatment and synbiotics (VSL#3 a probiotic, and Yogut, prebiotic and probiotic combination) for 6 weeks, while the control arm will receive standard medical treatment with a placebo. The patients will be followed up for 6 months to study the clinical and biochemical outcomes. The primary objective is to compare the difference in the occurrence of infectious complications between the patients who receive synbiotics versus placebo during the 6-month period following LDLT. The secondary objectives include assessing the qualitative and quantitative change in microbiota with synbiotics and LDLT, adverse reactions due to synbiotics, and post-LT morbidity and mortality. The minimum sample size comes to 71 in each group. The first 50 patients in the study protocol will undergo gut microbiome analysis using 16s metagenomic and nanopore sequencing to analyse the microbial composition before starting synbiotics/placebo and at 6 weeks after LDLT.

ETHICS AND DISSEMINATION

The study is approved by the Research Ethics Committee of Amrita Institute of Medical Sciences, Kochi, India (IEC-AIMS-2022-GISUR-203) and registered in the Clinical Trial Registry of India (CTRI) CTRI/2022/10/046327. The results of the trial will be disseminated by presentation at national/international conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

CTRI/2022/10/046327 - Clinical Trial Registry of India.

The role of the comprehensive complication index in the prediction of tumor-related death in transplanted patients with hepatocellular carcinoma

Liver transplantation (LT) is the primary treatment for selected patients with hepatocellular carcinoma (HCC). However, HCC-related mortality post-LT remains a significant concern, with up to 10% of cases reported in international series. Identifying risk factors for adverse clinical outcomes is essential. We hypothesized that post-LT HCC-related mortality rates are higher in patients with a high (≥ 42) Comprehensive Complication Index (CCI) calculated at discharge. This study aims to compare post-LT HCC-related mortality rates between two groups of patients with high versus low CCI following LT for HCC. This study included data from seven collaborative European centers. A cohort of 1121 HCC patients transplanted between 2005 and 2019, surviving more than six months post-LT, was analyzed retrospectively. Patients were divided into two groups based on the CCI at discharge: Low-CCI Group (n = 942, 84.0%) and High-CCI Group (n = 179, 16.0%). An inverse probability of treatment weighting (IPTW) approach was applied for analysis. In the post-IPTW cohort, four multivariable logistic regression models with mixed effects identified independent risk factors for HCC-related death, overall death, recurrence, and early recurrence. A CCI score of ≥ 42 emerged as an independent risk factor across all models. Specifically, CCI ≥ 42 was associated with increased odds of HCC-related death (OR = 3.35; P < 0.0001), overall death (OR = 2.63; P < 0.0001), overall recurrence (OR = 2.09; P = 0.001), and early recurrence (OR = 1.88; P = 0.02). A CCI score at discharge should be considered a critical factor for recurrence and HCC-related mortality risk. Incorporating CCI into standard post-LT predictive models may enhance prognostic accuracy for adverse HCC outcomes.