Improving graft survival for patients undergoing liver transplantation

A Holistic Clustering Methodology for Liver Transplantation Survival

BACKGROUND

Liver transplants account for a high number of procedures with major investments from all stakeholders involved; however, limited studies address liver transplant population heterogeneity pretransplant predictive of posttransplant survival.

OBJECTIVE

The aim of the study was to identify novel and meaningful patient clusters predictive of mortality that explains the heterogeneity of liver transplant population, taking a holistic approach.

METHODS

A retrospective cohort study of 344 adult patients who underwent liver transplantation between 2008 through 2014. Predictors were summarized severity scores for comorbidities and other suboptimal health states grouped into 11 body systems, the primary reason for transplantation, demographics/environmental factors, and Model for End Liver Disease score. Logistic regression was used to compute the severity scores, hierarchical clustering with weighted Euclidean distance for clustering, Lasso-penalized regression for characterizing the clusters, and Kaplan-Meier analysis to compare survival across the clusters.

RESULTS

Cluster 1 included patients with more severe circulatory problems. Cluster 2 represented older patients with more severe primary disease, whereas Cluster 3 contained healthiest patients. Clusters 4 and 5 represented patients with musculoskeletal (e.g., pain) and endocrine problems (e.g., malnutrition), respectively. There was a statistically significant difference for mortality between clusters (p < .001).

CONCLUSIONS

This study developed a novel methodology to address heterogeneous and high-dimensional liver transplant population characteristics in a single study predictive of survival. A holistic approach for data modeling and additional psychosocial risk factors has the potential to address holistically nursing challenges on liver transplant care and research.

Predictors of Liver Transplant Patient Survival

Objective:

Liver transplantation is a costly and risky procedure, representing 25 050 procedures worldwide in 2013, with 6729 procedures performed in the United States in 2014. Considering the scarcity of organs and uncertainty regarding prognosis, limited studies address the variety of risk factors before transplantation that might contribute to predicting patient’s survival and therefore developing better models that address a holistic view of transplant patients. This critical review aimed to identify predictors of liver transplant patient survival included in large-scale studies and assess the gap in risk factors from a holistic approach using the Wellbeing Model and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.

Data Source:

Search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and PubMed from the 1980s to July 2014.

Study Selection:

Original longitudinal large-scale studies, of 500 or more subjects, published in English, Spanish, or Portuguese, which described predictors of patient survival after deceased donor liver transplantation.

Data Extraction:

Predictors were extracted from 26 studies that met the inclusion criteria.

Data Synthesis:

Each article was reviewed and predictors were categorized using a holistic framework, the Wellbeing Model (health, community, environment, relationship, purpose, and security dimensions).

Conclusions:

The majority (69.7%) of the predictors represented the Wellbeing Model Health dimension. There were no predictors representing the Wellbeing Dimensions for purpose and relationship nor emotional, mental, and spiritual health. This review showed that there is rigorously conducted research of predictors of liver transplant survival; however, the reported significant results were inconsistent across studies, and further research is needed to examine liver transplantation from a whole-person perspective.