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Alves JAS, Meirelles RF, Gonzales AM, David AI, Filho GDJL. Application of the Balance of Risk Score to Liver Transplantation. Transplant Proc 2023; 55:1416-1420. [PMID: 37087297 DOI: 10.1016/j.transproceed.2023.01.027] [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: 12/03/2022] [Accepted: 01/04/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND To evaluate the capacity of BARS to predict 90-day, 1-year, 3-year, and 5-year survival after liver transplantation (LTx). The Balance of Risk Score (BARS), proposed by the Swiss Hepato-pancreato-biliary and Transplant Center, University Hospital Zurich, Switzerland, was conceptualized to determine survival after LTx preemptively. SAMPLE AND METHODS This was a retrospective observational study on 866 cases of LTx among adults (>18 years) performed within the transplantation program at Hospital Israelita Albert Einstein between January 1, 2010, and December 31, 2015. Cases of loss from follow-up, split-liver transplantation, transplantation from a live donor, and combinations of LTx with transplantation of other organs were excluded. BARS was calculated for each transplantation performed. The survival estimates were accompanied by 95% CIs, and the associations between the variables of interest and the patients' overall survival were evaluated using Cox proportional risk models. Receiver operating characteristic curves and the estimated area under the curve were used with 95% CIs and P values for the equality test on the area at .5. RESULTS The area under the curve for the 90-day period was 0.725, with a 95% CI from 0.670 to 0.81 and a P value < .001 for the equality test at 0.5. In the stratified analysis, the score of 18 presented the highest sensitivity, taking a minimum specificity of 90%. The BARS >18 gave rise to a significant decline in survival, from 89.7% to 60.4% over the first 90 days, from 83.3% to 56.2% over a 1-year period, from 75.7% to 49.5% over 3 years, and from 72.2% to 43.4% over 5 years. CONCLUSION The BARS was shown to be reproducible and can be used as a tool for estimating survival among LTx patients. LTx performed on patients with BARS >18 significantly predicts lower survival for such patients.
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Affiliation(s)
| | - Roberto F Meirelles
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Federal University of São Paulo, São Paulo, Brazil
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2
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Saner FH, Frey A, Stüben BO, Hoyer DP, Willuweit K, Daniel M, Rashidi-Alavieh J, Treckmann JW, Schmidt HH. Transplantation for Primary Sclerosing Cholangitis: Outcomes and Recurrence. J Clin Med 2023; 12:jcm12103405. [PMID: 37240511 DOI: 10.3390/jcm12103405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/07/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Primary sclerosing cholangitis (PSC) is characterized by inflammation of the whole bile duct system. Liver transplantation is only approved as a curative treatment when it comes to end-stage liver disease. The aim of our study was to assess morbidity, survival rates and PSC recurrence and the impact of donor characteristics in long-term follow-up. This was an IRB-approved retrospective study. A total of 82 patients were identified who were transplanted between January 2010 and December 2021 for PSC. Among these patients, 76 adult liver transplant PSC patients and their corresponding donors were analyzed. Three pediatric cases and three adult patients with a follow-up within <1 year were excluded from further analysis. Median (range) age was 47 years (18-70) with a median (range) lab-MELD of 16 (7-40). Median (range) ICU and hospital stays were 4.6 days (0-147) and 21 days (1-176), respectively. The majority of patients suffered from Crohn's disease or ulcerative colitis as a concomitant comorbidity (65.8%). The ten-year survival rate was 74.6%. A significantly lower lab-MELD score was identified in patients surviving for > 10 years (15 vs. 22, p = 0.004). Most patients (65%) passed in the first year following transplantation, with primary non-function (PNF), sepsis and arterial thrombosis being the most common causes of death. Donor characteristics did not affect patient survival. Patients with PSC show excellent 10-year survival rates. While the lab-MELD score significantly affected long term outcomes, donor characteristics did not affect survival rates.
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Affiliation(s)
- Fuat H Saner
- Department of General- and Visceral- and Transplant Surgery, Essen University Medical Center, 45147 Essen, Germany
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia
| | - Alexandra Frey
- Department of Gastroenterology, Hepatology and Transplantation Medicine, Essen University Medical Center, 45147 Essen, Germany
| | - Björn-Ole Stüben
- Department of General- and Visceral- and Transplant Surgery, Essen University Medical Center, 45147 Essen, Germany
| | - Dieter P Hoyer
- Department of General- and Visceral- and Transplant Surgery, Essen University Medical Center, 45147 Essen, Germany
| | - Katharina Willuweit
- Department of Gastroenterology, Hepatology and Transplantation Medicine, Essen University Medical Center, 45147 Essen, Germany
| | - Martina Daniel
- Department of Gastroenterology, Hepatology and Transplantation Medicine, Essen University Medical Center, 45147 Essen, Germany
| | - Jassin Rashidi-Alavieh
- Department of Gastroenterology, Hepatology and Transplantation Medicine, Essen University Medical Center, 45147 Essen, Germany
| | - Jurgen W Treckmann
- Department of General- and Visceral- and Transplant Surgery, Essen University Medical Center, 45147 Essen, Germany
| | - Hartmut H Schmidt
- Department of Gastroenterology, Hepatology and Transplantation Medicine, Essen University Medical Center, 45147 Essen, Germany
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3
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Junger H, Mühlbauer M, Brennfleck FW, Schurr LA, Goetz M, Eggenhofer E, Kirchner G, Evert K, Fichtner-Feigl S, Geissler EK, Schlitt HJ, Brunner SM. Early γGT and bilirubin levels as biomarkers for regeneration and outcomes in damaged bile ducts after liver transplantation. Clin Transplant 2023; 37:e14880. [PMID: 36522802 DOI: 10.1111/ctr.14880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 10/25/2022] [Accepted: 12/03/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Early patient and allograft survival after liver transplantation (LT) depend primarily on parenchymal function, but long-term allograft success relies often on biliary-tree function. We examined parameters related to cholangiocyte damage that predict poor long-term LT outcomes after donation after brain death (DBD). METHODS Sixty bile ducts (BD) were assessed by a BD damage-score and divided into groups with "major" BD-damage (n = 33) and "no relevant" damage (n = 27) during static cold storage. Patients with "major" BD damage were further investigated by measuring biliary excretion parameters in the first 14 days post-LT (followed-up for 60-months). RESULTS Patients who received LT showing "major" BD damage had significantly worse long-term patient survival, versus grafts with "no relevant" damage (p = .03). When "major" BD damage developed, low bilirubin levels (p = .012) and high gamma-glutamyl transferase (GGT)/bilirubin ratio (p = .0003) were evident in the early post-LT phase (7-14 days) in patients who survived (> 60 months), compared to those who did not. "High risk" patients with bile duct damage and low GGT/bilirubin ratio had significantly shorter overall survival (p < .0001). CONCLUSIONS Once "major" BD damage occurs, a high GGT/bilirubin ratio in the early post-operative phase is likely indicator of liver and cholangiocyte regeneration, and thus a harbinger of good overall outcomes. "Major" BD damage without markers of regeneration identifies LT patients that could benefit from future repair therapies.
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Affiliation(s)
- Henrik Junger
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Marco Mühlbauer
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Frank W Brennfleck
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Leonhard A Schurr
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Markus Goetz
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Elke Eggenhofer
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Gabriele Kirchner
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany.,Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Katja Evert
- Department of Pathology, University Regensburg, Regensburg, Germany
| | - Stefan Fichtner-Feigl
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany.,Department of Surgery, University Hospital Freiburg, Freiburg, Germany
| | - Edward K Geissler
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany.,Fraunhofer Institute for Experimental Medicine and Toxicology, Regensburg, Germany
| | - Hans J Schlitt
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Stefan M Brunner
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
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4
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Magyar CTJ, Beldi G, Banz V. Impact of MELD 30-allocation policy on liver transplant outcomes in Italy: Considerations. J Hepatol 2022; 77:572-573. [PMID: 35358617 DOI: 10.1016/j.jhep.2022.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/13/2022] [Accepted: 03/04/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Christian Tibor Josef Magyar
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Vanessa Banz
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
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5
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Dancs PT, Saner FH, Benkö T, Molmenti EP, Büchter M, Paul A, Hoyer DP. Balancing Outcome vs. Urgency in Modern Liver Transplantation. Front Surg 2022; 9:853727. [PMID: 35310440 PMCID: PMC8931036 DOI: 10.3389/fsurg.2022.853727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 01/31/2022] [Indexed: 11/15/2022] Open
Abstract
Background Current allocation mechanisms for liver transplantation (LT) overemphasize emergency, leading to poorer longtime outcomes. The utility was introduced to recognized outcomes in allocation. Recently, Molinari proposed a predictive outcome model based on recipient data. Aims The aims of this study were to validate this model and to combine it with the utility to emphasize outcome in allocation. Methods We retrospectively analyzed 734 patients who were transplanted between January 2010 and December 2019. Points were assigned as in Molinari's model and the score sum was correlated with observed 90-day mortality. The utility was calculated as the product of 1-year survival times 3-month mortality on the waiting list. The weighting of different compounds was introduced, and utility curves were calculated. Model for End-Stage Liver Disease (MELD) scores according to maximal utility were determined. Results In total, 120 patients (16.3%) had died within 90 days after LT. Higher MELD score, obesity, and hemodialysis prior to LT were confirmed risk factors. Overall survival was 83.8 and 77.4% after 90 days and 12 months, respectively. General utility culminated at MELD scores >35 in the overall population. Emphasizing the outcome shifted the maximal utility to lower MELD scores depending on Molinari scores. Conclusions Emphasizing outcome, at least in certain recipient risk categories, might improve the longtime outcomes and might be integrated into allocation models.
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Affiliation(s)
- Peter T. Dancs
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Fuat H. Saner
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Tamas Benkö
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Ernesto P. Molmenti
- Department of Surgery, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY, United States
| | - Matthias Büchter
- Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Andreas Paul
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Dieter P. Hoyer
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
- *Correspondence: Dieter P. Hoyer
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Ravaioli M, Lai Q, Sessa M, Ghinolfi D, Fallani G, Patrono D, Di Sandro S, Avolio A, Odaldi F, Bronzoni J, Tandoi F, De Carlis R, Pascale MM, Mennini G, Germinario G, Rossi M, Agnes S, De Carlis L, Cescon M, Romagnoli R, De Simone P. Impact of MELD 30-allocation policy on liver transplant outcomes in Italy. J Hepatol 2022; 76:619-627. [PMID: 34774638 DOI: 10.1016/j.jhep.2021.10.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/04/2021] [Accepted: 10/15/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS In Italy, since August 2014, liver transplant (LT) candidates with model for end-stage liver disease (MELD) scores ≥30 receive national allocation priority. This multicenter cohort study aims to evaluate time on the waiting list, dropout rate, and graft survival before and after introducing the macro-area sharing policy. METHODS A total of 4,238 patients registered from 2010 to 2018 were enrolled and categorized into an ERA-1 Group (n = 2,013; before August 2014) and an ERA-2 Group (n = 2,225; during and after August 2014). A Cox proportional hazards model was used to estimate the hazard ratio (HR) of receiving a LT or death between the two eras. The Fine-Gray model was used to estimate the HR for dropout from the waiting list and graft loss, considering death as a competing risk event. A Fine-Gray model was also used to estimate risk factors of graft loss. RESULTS Patients with MELD ≥30 had a lower median time on the waiting list (4 vs.12 days, p <0.001) and a higher probability of being transplanted (HR 2.27; 95% CI 1.78-2.90; p = 0.001) in ERA-2 compared to ERA-1. The subgroup analysis on 3,515 LTs confirmed ERA-2 (odds ratio 0.56; 95% CI 0.46-0.68; p = 0.001) as a protective factor for better graft survival rate. The protective variables for lower dropouts on the waiting list were: ERA-2, high-volume centers, no competition centers, male recipients, and hepatocellular carcinoma. The protective variables for graft loss were high-volume center and ERA-2, while MELD ≥30 remained related to a higher risk of graft loss. CONCLUSIONS The national MELD ≥30 priority allocation was associated with improved patient outcomes, although MELD ≥30 was associated with a higher risk of graft loss. Transplant center volumes and competition among centers may have a role in recipient prioritization and outcomes. CLINICAL TRIAL NUMBER NCT04530240 LAY SUMMARY: Italy introduced a new policy in 2014 to give national allocation priority to patients with a model for end-stage liver disease (MELD) score ≥30 (i.e. very sick patients). This policy has led to more liver transplants, fewer dropouts, and shorter waiting times for patients with MELD ≥30. However, a higher risk of graft loss still burdens these cases. Transplant center volumes and competition among centers may have a role in recipient prioritization and outcomes.
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Affiliation(s)
- Matteo Ravaioli
- Dipartimento di Chirurgia Generale e Trapianti, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), University of Bologna, Bologna, Italy.
| | - Quirino Lai
- Unità di Chirurgia Generale e Trapianti d'Organo, Dipartimento di Chirurgia Generale e Specialistica, Sapienza Università di Roma, Azienda Ospedaliero-Universitaria Policlinico Umberto I di Roma, Italy
| | - Maurizio Sessa
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Davide Ghinolfi
- Chirurgia epatobiliare e trapianto di fegato, Ospedale della Scuola medica dell'Università di Pisa, Italy
| | - Guido Fallani
- Dipartimento di Chirurgia Generale e Trapianti, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Damiano Patrono
- Centro trapianti di fegato, Chirurgia Generale 2U, Università di Torino, AOU Città della Salute e della Scienza, Torino, Italy
| | - Stefano Di Sandro
- Dipartimento di Chirurgia Generale e Trapianti, Ospedale Niguarda Ca 'Granda, Milano, Italy
| | - Alfonso Avolio
- Dipartimento di Chirurgia - Servizio Trapianti, Università Cattolica "A. Gemelli" di Roma, Italy
| | - Federica Odaldi
- Dipartimento di Chirurgia Generale e Trapianti, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Jessica Bronzoni
- Chirurgia epatobiliare e trapianto di fegato, Ospedale della Scuola medica dell'Università di Pisa, Italy
| | - Francesco Tandoi
- Centro trapianti di fegato, Chirurgia Generale 2U, Università di Torino, AOU Città della Salute e della Scienza, Torino, Italy
| | - Riccardo De Carlis
- Dipartimento di Chirurgia Generale e Trapianti, Ospedale Niguarda Ca 'Granda, Milano, Italy
| | - Marco Maria Pascale
- Unità di Chirurgia Generale e Trapianti d'Organo, Dipartimento di Chirurgia Generale e Specialistica, Sapienza Università di Roma, Azienda Ospedaliero-Universitaria Policlinico Umberto I di Roma, Italy
| | - Gianluca Mennini
- Unità di Chirurgia Generale e Trapianti d'Organo, Dipartimento di Chirurgia Generale e Specialistica, Sapienza Università di Roma, Azienda Ospedaliero-Universitaria Policlinico Umberto I di Roma, Italy
| | - Giuliana Germinario
- Dipartimento di Chirurgia Generale e Trapianti, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), University of Bologna, Bologna, Italy
| | - Massimo Rossi
- Unità di Chirurgia Generale e Trapianti d'Organo, Dipartimento di Chirurgia Generale e Specialistica, Sapienza Università di Roma, Azienda Ospedaliero-Universitaria Policlinico Umberto I di Roma, Italy
| | - Salvatore Agnes
- Dipartimento di Chirurgia - Servizio Trapianti, Università Cattolica "A. Gemelli" di Roma, Italy
| | - Luciano De Carlis
- Dipartimento di Chirurgia Generale e Trapianti, Ospedale Niguarda Ca 'Granda, Milano, Italy
| | - Matteo Cescon
- Dipartimento di Chirurgia Generale e Trapianti, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), University of Bologna, Bologna, Italy
| | - Renato Romagnoli
- Centro trapianti di fegato, Chirurgia Generale 2U, Università di Torino, AOU Città della Salute e della Scienza, Torino, Italy
| | - Paolo De Simone
- Chirurgia epatobiliare e trapianto di fegato, Ospedale della Scuola medica dell'Università di Pisa, Italy
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7
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The role of the comprehensive complication index for the prediction of survival after liver transplantation. Updates Surg 2020; 73:209-221. [PMID: 32892294 PMCID: PMC7889667 DOI: 10.1007/s13304-020-00878-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/30/2020] [Indexed: 01/11/2023]
Abstract
In the last years, several scoring systems based on pre- and post-transplant parameters have been developed to predict early post-LT graft function. However, some of them showed poor diagnostic abilities. This study aims to evaluate the role of the comprehensive complication index (CCI) as a useful scoring system for accurately predicting 90-day and 1-year graft loss after liver transplantation. A training set (n = 1262) and a validation set (n = 520) were obtained. The study was registered at https://www.ClinicalTrials.gov (ID: NCT03723317). CCI exhibited the best diagnostic performance for 90 days in the training (AUC = 0.94; p < 0.001) and Validation Sets (AUC = 0.77; p < 0.001) when compared to the BAR, D-MELD, MELD, and EAD scores. The cut-off value of 47.3 (third quartile) showed a diagnostic odds ratio of 48.3 and 7.0 in the two sets, respectively. As for 1-year graft loss, CCI showed good performances in the training (AUC = 0.88; p < 0.001) and validation sets (AUC = 0.75; p < 0.001). The threshold of 47.3 showed a diagnostic odds ratio of 21.0 and 5.4 in the two sets, respectively. All the other tested scores always showed AUCs < 0.70 in both the sets. CCI showed a good stratification ability in terms of graft loss rates in both the sets (log-rank p < 0.001). In the patients exceeding the CCI ninth decile, 1-year graft survival rates were only 0.7% and 23.1% in training and validation sets, respectively. CCI shows a very good diagnostic power for 90-day and 1-year graft loss in different sets of patients, indicating better accuracy with respect to other pre- and post-LT scores.Clinical Trial Notification: NCT03723317.
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8
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Artzner T, Michard B, Weiss E, Barbier L, Noorah Z, Merle JC, Paugam-Burtz C, Francoz C, Durand F, Soubrane O, Pirani T, Theocharidou E, O'Grady J, Bernal W, Heaton N, Salamé E, Bucur P, Barraud H, Lefebvre F, Serfaty L, Besch C, Bachellier P, Schneider F, Levesque E, Faitot F. Liver transplantation for critically ill cirrhotic patients: Stratifying utility based on pretransplant factors. Am J Transplant 2020; 20:2437-2448. [PMID: 32185866 DOI: 10.1111/ajt.15852] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/19/2020] [Accepted: 02/27/2020] [Indexed: 01/25/2023]
Abstract
The aim of this study was to produce a prognostic model to help predict posttransplant survival in patients transplanted with grade-3 acute-on-chronic liver failure (ACLF-3). Patients with ACLF-3 who underwent liver transplantation (LT) between 2007 and 2017 in 5 transplant centers were included (n = 152). Predictors of 1-year mortality were retrospectively screened and tested on a single center training cohort and subsequently tested on an independent multicenter cohort composed of the 4 other centers. Four independent pretransplant risk factors were associated with 1-year mortality after transplantation in the training cohort: age ≥53 years (P = .044), pre-LT arterial lactate level ≥4 mml/L (P = .013), mechanical ventilation with PaO2 /FiO2 ≤ 200 mm Hg (P = .026), and pre-LT leukocyte count ≤10 G/L (P = .004). A simplified version of the model was derived by assigning 1 point to each risk factor: the transplantation for Aclf-3 model (TAM) score. A cut-off at 2 points distinguished a high-risk group (score >2) from a low-risk group (score ≤2) with 1-year survival of 8.3% vs 83.9% respectively (P < .001). This model was subsequently validated in the independent multicenter cohort. The TAM score can help stratify posttransplant survival and identify an optimal transplantation window for patients with ACLF-3.
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Affiliation(s)
- Thierry Artzner
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Baptiste Michard
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Emmanuel Weiss
- Département Anesthésie et Réanimation, AP-HP, Hôpital Beaujon, Clichy, France.,UMR S 1149 Inserm/Université Paris Diderot, Paris, France
| | - Louise Barbier
- Service de Chirurgie Digestive et Transplantation Hépatique, CHU Trousseau, Université de Tours, Tours, France.,FHU SUPORT (Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation), Strasbourg, France
| | - Zair Noorah
- Service d'Anesthésie et Réanimation Chirurgicale, Hôpital Henri Mondor, Créteil, France
| | - Jean-Claude Merle
- Service d'Anesthésie et Réanimation Chirurgicale, Hôpital Henri Mondor, Créteil, France
| | - Catherine Paugam-Burtz
- Département Anesthésie et Réanimation, AP-HP, Hôpital Beaujon, Clichy, France.,UMR S 1149 Inserm/Université Paris Diderot, Paris, France
| | - Claire Francoz
- UMR S 1149 Inserm/Université Paris Diderot, Paris, France.,Département d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - François Durand
- UMR S 1149 Inserm/Université Paris Diderot, Paris, France.,Département d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Olivier Soubrane
- UMR S 1149 Inserm/Université Paris Diderot, Paris, France.,Service de Chirurgie Hépato-Pancréato-Biliaire, AP-HP Hôpital Beaujon, Clichy, France
| | - Tasneem Pirani
- Institute of Liver Studies, King's College Hospital, London, UK
| | | | - John O'Grady
- Institute of Liver Studies, King's College Hospital, London, UK
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Ephrem Salamé
- Service de Chirurgie Digestive et Transplantation Hépatique, CHU Trousseau, Université de Tours, Tours, France.,FHU SUPORT (Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation), Strasbourg, France
| | - Petru Bucur
- Service de Chirurgie Digestive et Transplantation Hépatique, CHU Trousseau, Université de Tours, Tours, France.,FHU SUPORT (Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation), Strasbourg, France
| | - Hélène Barraud
- FHU SUPORT (Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation), Strasbourg, France.,Service d'Hépatologie, CHU Trousseau, Université de Tours, France
| | - François Lefebvre
- Service de Santé Publique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Lawrence Serfaty
- Service d'Hépato-Gastro-Entérologie et d'Assistance Nutritive, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Camille Besch
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Philippe Bachellier
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Francis Schneider
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,UMR S 1121 Inserm/Université de Strasbourg, Strasbourg, France
| | - Eric Levesque
- Service d'Anesthésie et Réanimation Chirurgicale, Hôpital Henri Mondor, Créteil, France
| | - François Faitot
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Laboratoire ICube, UMR 7357, Université de Strasbourg, Strasbourg, France
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9
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The Effects of MELD-Based Liver Allocation on Patient Survival and Waiting List Mortality in a Country with a Low Donation Rate. J Clin Med 2020; 9:jcm9061929. [PMID: 32575598 PMCID: PMC7356806 DOI: 10.3390/jcm9061929] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/08/2020] [Accepted: 06/15/2020] [Indexed: 01/17/2023] Open
Abstract
The Model for End-Stage Liver Disease (MELD)-based allocation system was implemented in Germany in 2006 in order to reduce waiting list mortality. The purpose of this study was to evaluate post-transplant results and waiting list mortality since the introduction of MELD-based allocation in our center and in Germany. Adult liver transplantation at the Charité—Universitätsmedizin Berlin was assessed retrospectively between 2005 and 2012. In addition, open access data from Eurotransplant (ET) and the German Organ Transplantation Foundation (DSO) were evaluated. In our department, 861 liver transplantations were performed from 2005 to 2012. The mean MELD score calculated with the laboratory values last transmitted to ET before organ offer (labMELD) at time of transplantation increased to 20.1 from 15.8 (Pearson’s R = 0.121, p < 0.001, confidence interval (CI) = 0.053–0.187). Simultaneously, the number of transplantations per year decreased from 139 in 2005 to 68 in 2012. In order to overcome this organ shortage the relative number of utilized liver donors in Germany has increased (85% versus 75% in non-German ET countries). Concomitantly, 5-year patient survival decreased from 79.9% in 2005 to 60.3% in 2012 (p = 0.048). At the same time, the ratio of waiting list mortality vs. active-listed patients nearly doubled in Germany (Spearman’s rho = 0.903, p < 0.001, CI = 0.634–0.977). In low-donation areas, MELD-based liver allocation may require reconsideration and inclusion of prognostic outcome factors.
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10
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A Systematic Review for Variables to Be Collected in a Transplant Database for Improving Risk Prediction. Transplantation 2020; 103:2591-2601. [PMID: 30768569 DOI: 10.1097/tp.0000000000002652] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND This systematic review was commissioned to identify new variables associated with transplant outcomes that are not currently collected by the Organ Procurement and Transplantation Network (OPTN). METHODS We identified 81 unique studies including 1 193 410 patients with median follow-up of 36 months posttransplant, reporting 108 unique risk factors. RESULTS Most risk factors (104) were recipient related; few (4) were donor related. Most risk factors were judged to be practical and feasible to routinely collect. Relative association measures were small to moderate for most risk factors (ranging between 1.0 and 2.0). The strongest relative association measure for a heart transplant outcome with a risk factor was 8.6 (recipient with the previous Fontan operation), for a kidney transplant 2.8 (sickle cell nephropathy as primary cause of end-stage renal disease), for a liver transplant 14.3 (recipient serum ferritin >500 µg/L), and for a lung transplant 6.3 (Burkholderia cepacia complex infection for 1 y or less). OPTN may consider some of these 108 variables for future collection to enhance transplant research and clinical care. CONCLUSIONS Evidence-based approaches can be used to determine variables collected in databases and registries. Several candidate variables have been identified for OPTN.
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11
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Wiering L, Öllinger R, Kruppa J, Schoeneberg U, Dziodzio T, Jara M, Biebl M, Dargie R, Raschzok N, Schöning W, Eurich D, Schmelzle M, Sauer IM, Pratschke J, Ritschl PV. Hospitalization Before Liver Transplantation Predicts Posttransplant Patient Survival: A Propensity Score-Matched Analysis. Liver Transpl 2020; 26:628-639. [PMID: 32159923 DOI: 10.1002/lt.25748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 01/22/2020] [Accepted: 02/11/2020] [Indexed: 01/13/2023]
Abstract
In contrast to donor factors predicting outcomes of liver transplantation (LT), few suitable recipient parameters have been identified. To this end, we performed an in-depth analysis of hospitalization status and duration prior to LT as a potential risk factor for posttransplant outcome. The pretransplant hospitalization status of all patients undergoing LT between 2005 and 2016 at the Charité-Universitätsmedizin Berlin was analyzed retrospectively using propensity score matching. At the time of organ acceptance, 226 of 1134 (19.9%) recipients were hospitalized in an intensive care unit (ICU), 146 (12.9%) in a regular ward (RW) and 762 patients (67.2%) were at home. Hospitalized patients (RW and ICU) compared with patients from home showed a dramatically shorter 3-month survival (78.7% versus 94.4%), 1-year survival (66.3% versus 87.3%), and 3-year survival (61.7% versus 81.7%; all P < 0.001), whereas no significant difference was detected for 3-year survival between ICU and RW patients (61.5% versus 62.3%; P = 0.60). These results remained significant after propensity score matching. Furthermore, in ICU patients, but not in RW patients, survival correlated with days spent in the ICU before LT (1-year survival: 1-6 versus 7-14 days: 73.7% versus 60.5%, P = 0.04; 7-14 days versus >14 days, 60.5% versus 51.0%, P = 0.006). In conclusion, hospitalization status before transplantation is a valuable predictor of patient survival following LT.
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Affiliation(s)
- Leke Wiering
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen Kruppa
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Uwe Schoeneberg
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tomasz Dziodzio
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximillian Jara
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Biebl
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Richard Dargie
- Division of Emergency and Acute Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Charité Clinician Scientist Program, Berlin Institute of Health, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Dennis Eurich
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Igor M Sauer
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Paul V Ritschl
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Charité Clinician Scientist Program, Berlin Institute of Health, Berlin, Germany
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12
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Martínez JA, Pacheco S, Bachler JP, Jarufe N, Briceño E, Guerra JF, Benítez C, Wolff R, Barrera F, Arrese M. Accuracy of the BAR score in the prediction of survival after liver transplantation. Ann Hepatol 2020; 18:386-392. [PMID: 31036493 DOI: 10.1016/j.aohep.2019.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/21/2018] [Accepted: 01/23/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM The Balance of Risk (BAR) Score, a simple scoring system that combines six independent donor and recipient variables to predict outcome after liver transplantation (LT), was validated in a large U.S./European cohort of patients. This study aims to assess the performance of the BAR score to predict survival after liver transplantation and determine the factors associated with short and long-term survival in Latin-American patients. MATERIAL AND METHODS A retrospective cohort study was performed in 194 patients [112 (55.4%) males; mean age 52±14 years] who underwent 202 LT during the period 2003-2015. Demographic, clinical, pathological and surgical variables, as well as mortality and survival rates, were analyzed. The BAR score was investigated through a receiver operating characteristics (ROC) curve with the calculation of the area under the curve (AUC) to evaluate the predictive score power for 3-month, 1 and 5-year mortality in a matched donor-recipient cohort. Youden index was calculated to identify optimal cutoff points. RESULTS The AUC of BAR score in predicting 3-month, 1-year and 5-year mortality were 0.755 (CI95% 0.689-0.812), 0.702 (CI95% 0.634-0.764) and 0.610 (CI95% 0.539-0.678) respectively. The best cut-off point was a BAR score ≥15 points. In the multivariate analysis BAR score <15 was associated with higher survival rates at 3 months and 1 and 5-years. CONCLUSIONS BAR score <15 points is an independent predictor of better short and long-term survival in Latin-American patients undergoing LT. The BAR scoring system has an adequate diagnostic capacity allowing to predict 3 and 12-month mortality.
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Affiliation(s)
- Jorge A Martínez
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile.
| | - Sergio Pacheco
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Jean P Bachler
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Nicolás Jarufe
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Eduardo Briceño
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Juan F Guerra
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Carlos Benítez
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Rodrigo Wolff
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Francisco Barrera
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Marco Arrese
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
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13
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Ershoff BD, Lee CK, Wray CL, Agopian VG, Urban G, Baldi P, Cannesson M. Training and Validation of Deep Neural Networks for the Prediction of 90-Day Post-Liver Transplant Mortality Using UNOS Registry Data. Transplant Proc 2020; 52:246-258. [PMID: 31926745 DOI: 10.1016/j.transproceed.2019.10.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/22/2019] [Accepted: 10/06/2019] [Indexed: 12/11/2022]
Abstract
Prediction models of post-liver transplant mortality are crucial so that donor organs are not allocated to recipients with unreasonably high probabilities of mortality. Machine learning algorithms, particularly deep neural networks (DNNs), can often achieve higher predictive performance than conventional models. In this study, we trained a DNN to predict 90-day post-transplant mortality using preoperative variables and compared the performance to that of the Survival Outcomes Following Liver Transplantation (SOFT) and Balance of Risk (BAR) scores, using United Network of Organ Sharing data on adult patients who received a deceased donor liver transplant between 2005 and 2015 (n = 57,544). The DNN was trained using 202 features, and the best DNN's architecture consisted of 5 hidden layers with 110 neurons each. The area under the receiver operating characteristics curve (AUC) of the best DNN model was 0.703 (95% CI: 0.682-0.726) as compared to 0.655 (95% CI: 0.633-0.678) and 0.688 (95% CI: 0.667-0.711) for the BAR score and SOFT score, respectively. In conclusion, despite the complexity of DNN, it did not achieve a significantly higher discriminative performance than the SOFT score. Future risk models will likely benefit from the inclusion of other data sources, including high-resolution clinical features for which DNNs are particularly apt to outperform conventional statistical methods.
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Affiliation(s)
- Brent D Ershoff
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, California, United States.
| | - Christine K Lee
- Department of Biomedical Engineering, University of California at Irvine, Irvine, California, United States
| | - Christopher L Wray
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, California, United States
| | - Vatche G Agopian
- Department of Surgery, Dumont-UCLA Transplant and Liver Cancer Centers, University of California at Los Angeles, Los Angeles, California, United States
| | - Gregor Urban
- Department of Computer Science, University of California at Irvine, Irvine, California, United States
| | - Pierre Baldi
- Department of Biomedical Engineering, University of California at Irvine, Irvine, California, United States; Department of Computer Science, University of California at Irvine, Irvine, California, United States
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, California, United States
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14
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Ingraham NE, Tignanelli CJ, Menk J, Chipman JG. Pre- and Peri-Operative Factors Associated with Chronic Critical Illness in Liver Transplant Recipients. Surg Infect (Larchmt) 2019; 21:246-254. [PMID: 31618109 DOI: 10.1089/sur.2019.192] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Chronic critical illness (CCI) is a new and increasing entity that accounts for substantial cost despite its low incidence. We hypothesized that patients with end-stage liver failure undergoing liver transplant would be at high risk for developing CCI. With limited liver donors it is essential to understand pre- and peritransplant predictors of CCI. Methods: To accomplish this we performed a retrospective cohort study at a large academic transplant center of all adult liver transplant patients from 2011 to 2017. We defined CCI as the need for mechanical ventilation for seven days or more post-transplant. Recipients who had re-transplantation during their index admission, acute rejection, or who died during transplant surgery were excluded. Logistic regression was performed using the Akaike information criterion (AIC) and the likelihood ratio test. Results: We identified 382 transplant recipients. Forty-five (11.8%) developed CCI. Univariable analysis identified 16 pre-transplant factors associated with post-transplant CCI. Subsequent multivariable logistic regression identified eight independent factors associated with CCI in liver transplant recipients including previous liver transplant, acute renal failure, frailty, lower albumin level, higher international normalized ratio, need for mechanical ventilation, and higher systolic pulmonary artery pressure. Pre-transplant factors associated with protection against CCI included higher Model for End-Stage Liver Disease (MELD) score. Conclusion: The incidence of CCI post-liver transplant is similar to the general population admitted to the intensive care unit. Pre-transplant factors associated with CCI can help identify at-risk patients, and furthermore, promote further research and interventions with the goal to decrease the incidence of CCI in the liver transplant recipients.
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Affiliation(s)
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota.,Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota.,Department of Surgery, North Memorial Health Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Jeremiah Menk
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey G Chipman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota.,Division of Critical Care and Acute Care Surgery, University of Minnesota, Minneapolis, Minnesota
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15
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Iwamura S, Kaido T, Morita S, Miyachi Y, Yao S, Shirai H, Kobayashi A, Hamaguchi Y, Kamo N, Yagi S, Uemoto S. Risk-benefit point of the Model for End-stage Liver Disease score in patients waiting for deceased-donor liver transplantation: A single-center experience. Hepatol Res 2019; 49:687-694. [PMID: 30698359 DOI: 10.1111/hepr.13320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/09/2019] [Accepted: 01/23/2019] [Indexed: 02/08/2023]
Abstract
AIM To clarify the risk-benefit point of the Model for End-stage Liver Disease (MELD) score in patients waiting for deceased-donor liver transplantation (DDLT). METHODS The present study retrospectively investigated 213 patients registered on the waiting list at Kyoto University (Kyoto, Japan) between 2005 and 2016. Patients were stratified by MELD score (6-9/10-14/15-20/21-30/31-40) and classified into two groups: the DDLT group (30 patients) and the waiting group (183 patients). Their post-registration mortality risk and long-term survival were compared. RESULTS For all MELD categories, the mortality risk was lower in the DDLT group than in the waiting group. The hazard ratio of post-registration mortality decreased in the DDLT group compared to the waiting group as the MELD score increased (0.36/0.12/0.06/0.042/0.004). Survival was significantly better among patients in the DDLT group with a MELD score of 15 or more than among patients in the waiting group. CONCLUSION For all MELD categories, DDLT reduced the mortality risk of patients on the waiting list.
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Affiliation(s)
- Sena Iwamura
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshimi Kaido
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoshi Morita
- Department of Surgery, Biomedical Statistics and Bioinformatics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Miyachi
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Siyuan Yao
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hisaya Shirai
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Kobayashi
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuhei Hamaguchi
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Naoko Kamo
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shintaro Yagi
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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16
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Husen P, Hornung J, Benko T, Klein C, Willuweit K, Buechter M, Saner FH, Paul A, Treckmann JW, Hoyer DP. Risk Factors for High Mortality on the Liver Transplant Waiting List in Times of Organ Shortage: A Single-Center Analysis. Ann Transplant 2019; 24:242-251. [PMID: 31048668 PMCID: PMC6519305 DOI: 10.12659/aot.914246] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Germany has the highest rate of patients dying or becoming unfit for transplant while waitlisted within the Eurotransplant region. Therefore, the aim of the current study was to analyze mortality as well as risk factors for mortality of candidates listed for liver transplantation at our center. MATERIAL AND METHODS Between 01/2011 and 12/2013, 481 adult patients were listed for primary liver transplantation (LT) at a single German center. Clinical and laboratory parameters were prospectively collected and retrospectively analyzed by univariable and multivariable logistic regression and Cox proportional hazards. RESULTS The mean model for end-stage liver disease (MELD) score of all liver transplant waitlist registrants (52.4 years, 60.1% male) was 16.9 (±10.2) at time of listing, with 10% of the listed patients having a MELD score of >32. After waitlisting, 133 (27.7%) candidates died within the follow-up period. Three-month-survival after listing for transplantation was 89% for patients ultimately receiving LT vs. 71.2% that did not receive LT (p<0.001). Multivariable analysis identified clinical parameters such as ICU treatment, preceding abdominal surgery, variceal bleeding, and ascites, as well as hydropic decompensation, as independent risk factors for waitlist mortality. CONCLUSIONS Consideration of independent risk factors of mortality within the MELD-based allocation system potentially improves assessment of individual urgency and might improve utilization of available organs.
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Affiliation(s)
- Peri Husen
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Julian Hornung
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Tamas Benko
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian Klein
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Katharina Willuweit
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Matthias Buechter
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Fuat Hakan Saner
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Juergen Walter Treckmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Dieter Paul Hoyer
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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17
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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.
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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
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18
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[Frontiers in liver transplantation in indication and techniques]. Chirurg 2018; 90:102-109. [PMID: 30413847 DOI: 10.1007/s00104-018-0761-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The frontiers in liver transplantation are intrinsically expansions of indications, e.g. hepatocellular carcinoma and (perihilar) cholangiocarcinoma, recipients with more severe concomitant diagnoses or "soft" contraindications and technically demanding reconstruction procedures of vascular structures (for portal vein thrombosis or aorto-hepatic conduits). In addition, an extension of the donor pool with suboptimal donor organs (old donors and steatotic livers) is of interest. METHODS This article presents the current situation based on personal experiences in daily practice and an appropriate literature review. RESULTS A significant reduction of 1‑year patient survival has been reported in Germany. The percentage of so-called marginal donor organs is inversely proportional to the very low donation rate and parallel to the waiting list mortality. Simultaneously, the proportion of inpatients with multiple organ failure is rising. CONCLUSION Results-oriented and controlled liver transplantation currently prohibits making inroads into the previously intrinsic frontiers. As long as the current circumstances do not change, a shift in the intrinsic frontiers of that which is surgically feasible will not be possible. The current situation forces the transplant surgeon to apply a more restrictive indications and organ acceptance policy. With this approach we can try to regain the previously excellent short- and long-term results of a 1‑year survival of 90% and a 20-year survival of 50%.
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19
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Benck U, Jung M, Krüger B, Grimm A, Weiss C, Yard BA, Lehner F, Kiessling A, Fischer L, Gallinat A, Kleespies A, Lorf T, Sucher R, Mönch C, Scherer MN, Rahmel A, Schemmer P, Krämer BK, Schnuelle P. Donor Dopamine Does Not Affect Liver Graft Survival: Evidence of Safety From a Randomized Controlled Trial. Liver Transpl 2018; 24:1336-1345. [PMID: 30102825 DOI: 10.1002/lt.25301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 05/15/2018] [Accepted: 06/04/2018] [Indexed: 12/28/2022]
Abstract
Treatment of donation after brain death (DBD) donors with low-dose dopamine improves the outcomes after kidney and heart transplantation. This study investigates the course of liver allografts from multiorgan donors enrolled in the randomized dopamine trial between 2004 and 2007 (clinicaltrials.gov identifier: NCT00115115). There were 264 hemodynamically stable DBDs who were randomly assigned to receive low-dose dopamine. Dopamine was infused at 4 μg/kg/minute for a median duration of 6.0 hours (interquartile range, 4.4-7.5 hours). We assessed the outcomes of 212 liver transplantations (LTs) performed at 32 European centers. Donors and recipients of both groups were very similar in baseline characteristics. Pretransplant laboratory Model for End-Stage Liver Disease score was not different in recipients of a dopamine-treated versus untreated graft (18 ± 8 versus 20 ± 8; P = 0.12). Mean cold ischemia time was 10.6 ± 2.9 versus 10.1 ± 2.8 hours (P = 0.24). No differences occurred in biopsy-proven rejection episodes (14.4% versus 15.7%; P = 0.85), requirement of hemofiltration (27.9% versus 31.5%; P = 0.65), the need for early retransplantation (5.8% versus 6.5%; P > 0.99), the incidence of primary nonfunction (7.7% versus 8.3%; P > 0.99), and in-hospital mortality (15.4% versus 14.8%; P > 0.99). Graft survival was 71.2% versus 73.2% and 59.6% versus 62.0% at 2 and 3 years (log-rank P = 0.71). Patient survival was 76.0% versus 78.7% and 65.4% versus 69.4% at 1 and 3 years (log-rank P = 0.50). In conclusion, donor pretreatment with dopamine has no short-term or longterm effects on outcome after LT. Therefore, low-dose dopamine pretreatment can safely be implemented as the standard of care in hemodynamically stable DBDs.
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Affiliation(s)
- Urs Benck
- Vth Department of Medicine, University Medical Center Mannheim
| | - Matthias Jung
- Vth Department of Medicine, University Medical Center Mannheim
| | - Bernd Krüger
- Vth Department of Medicine, University Medical Center Mannheim
| | - Anja Grimm
- Vth Department of Medicine, University Medical Center Mannheim
| | - Christel Weiss
- Department of Biomathematics and Medical Statistics, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Benito A Yard
- Vth Department of Medicine, University Medical Center Mannheim
| | - Frank Lehner
- Clinic for General, Abdominal and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Anja Kiessling
- Department of Abdominal, Visceral and Transplantation Surgery, Charité University Medicine, Berlin, Germany
| | - Lutz Fischer
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anja Gallinat
- Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Axel Kleespies
- Department of General, Visceral, Vascular and Transplant Surgery, Klinikum Grosshadern, Ludwig Maximilians University of Munich, Munich, Germany
| | - Thomas Lorf
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Georg August University, Göttingen, Germany
| | - Robert Sucher
- Department of Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Germany
| | - Christian Mönch
- Department of General, Visceral and Transplantation Surgery, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Marcus N Scherer
- Department of Surgery and Transplantation, University Hospital Regensburg, Regensburg, Germany
| | - Axel Rahmel
- German Organ Transplantation Foundation, Frankfurt, Germany
| | - Peter Schemmer
- Division of Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | | | - Peter Schnuelle
- Vth Department of Medicine, University Medical Center Mannheim.,Center for Renal Diseases, Weinheim, Germany
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20
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Staufer K, Kivaranovic D, Rasoul-Rockenschaub S, Soliman T, Trauner M, Berlakovich G. Waitlist mortality and post-transplant survival in patients with cholestatic liver disease - Impact of changes in allocation policy. HPB (Oxford) 2018; 20:916-924. [PMID: 29937419 DOI: 10.1016/j.hpb.2018.03.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 02/26/2018] [Accepted: 03/30/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study investigated the impact of Model of end-stage liver disease (MELD)-score introduction (MELDi) on waitlist mortality and post-liver transplant (LT) survival in primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC). METHODS LT candidates with PSC or PBC listed between January 1983 and March 2016 were included and followed until December 2016. After MELDi in 2004, PBC patients were listed according to labMELD, PSC patients according to the highest MELD during active cholangitis (chMELD). RESULTS In total, 100 PBC and 76 PSC patients were included. Waitlist mortality in PBC was significantly higher than in PSC (16% vs. 5.3%, p = 0.031), whereas PSC patients were significantly more often withdrawn from the waitlist due to improved condition (3.0% vs. 13.2%, p = 0.017). Competing risks analysis identified MELDi (HR = 4.12) and PBC (HR = 2.95) as significant predictors of waitlist mortality. Yet, overall 10 y-patient survival increased after MELDi by 18.8% leading to a 1 y-, 5 y-, and 10 y-patient survival of 98.2%, 70.6% and 70.6% in PBC, and 83.3%, 83.3%, and 80.6% in PSC, respectively. CONCLUSIONS PSC patients showed significantly lower waitlist mortality irrespective of MELDi, whereas in PBC waitlist mortality further increased after MELDi. Utility of MELD and chMELD did not impair post LT outcome.
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Affiliation(s)
- Katharina Staufer
- Department of Surgery, Division of Transplantation, Medical University of Vienna, Austria.
| | - Danijel Kivaranovic
- Department of Statistics and Operations Research, University of Vienna, Vienna, Austria
| | | | - Thomas Soliman
- Department of Surgery, Division of Transplantation, Medical University of Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Gabriela Berlakovich
- Department of Surgery, Division of Transplantation, Medical University of Vienna, Austria
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21
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Foerster F, Mittler J, Darstein F, Heise M, Marquardt JU, Wörns MA, Weinmann A, Sälter L, Hoppe-Lotichius M, Heinrich S, Kloeckner R, Pitton MB, Schattenberg JM, Sprinzl MF, Düber C, Otto G, Lang H, Galle PR, Zimmermann T. Recipient liver function before liver transplantation influences post-transplantation survival in patients with HCC. Eur J Intern Med 2018; 55:57-65. [PMID: 29859798 DOI: 10.1016/j.ejim.2018.05.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/05/2018] [Accepted: 05/20/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Liver transplantation (LT) is a complex yet curative treatment for a subset of patients with hepatocellular carcinoma (HCC). Due to donor organ shortage, patients with HCC need to be carefully selected for LT. In European countries, selection of patients is based on the Milan criteria, and donor organs are allocated by Eurotransplant. In order to optimize the utilization of available liver grafts, the outcome of HCC patients after LT needs to be closely monitored and evaluated. METHODS We assessed the outcome of 304 HCC patients who underwent LT at a tertiary medical center over a period of nearly 20 years (February 1998 until June 2017). RESULTS The 5-, 10- and 15-year survival rates were 62, 47 and 30%, respectively. The strongest survival-determining factor was tumour recurrence. Apart from a high tumour grading, the pre-LT MELD score was significantly and negatively associated with survival after LT. CONCLUSION Our results confirm the importance of recurrence for the outcome of HCC patients after LT and highlight the relevance of HCC patients' liver function before LT. Our findings encourage efforts to identify prognostically relevant factors for LT in HCC with the overall goal of refining the organ allocation system and maximizing the survival benefit after LT.
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Affiliation(s)
- Friedrich Foerster
- Department of Internal Medicine I, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Jens Mittler
- Department of General and Abdominal Surgery, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Felix Darstein
- Department of Internal Medicine I, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Michael Heise
- Department of General and Abdominal Surgery, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Jens U Marquardt
- Department of Internal Medicine I, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Marcus-Alexander Wörns
- Department of Internal Medicine I, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Arndt Weinmann
- Department of Internal Medicine I, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Lina Sälter
- Department of Internal Medicine I, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Maria Hoppe-Lotichius
- Department of General and Abdominal Surgery, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Stefan Heinrich
- Department of General and Abdominal Surgery, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Michael B Pitton
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Jörn M Schattenberg
- Department of Internal Medicine I, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Martin F Sprinzl
- Department of Internal Medicine I, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Christoph Düber
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Gerd Otto
- Department of General and Abdominal Surgery, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Hauke Lang
- Department of General and Abdominal Surgery, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany
| | - Tim Zimmermann
- Department of Internal Medicine I, University Medical Center Mainz, Germany; Interdiscliplinary Transplantation Center (ITx), Mainz, Germany.
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22
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Heise M, Weiler N, Iken S, Welker MW, Zeuzem S, Bechstein WO, Schnitzbauer AA. Liver Transplantation in Acute-on-Chronic Liver Failure: Considerations for a Systematic Approach to Decision Making. Visc Med 2018; 34:291-294. [PMID: 30345287 DOI: 10.1159/000492137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Acute-on-chronic liver failure (ACLF) is a complex disease with deteriorating liver and kidney function and associated organ failure in patients with chronic liver disease. Methods This is a concise overview for bedside and algorithmic decision making in patients with ACLF based on the most recent literature. Results Diagnosis and dynamics of ACLF can be easily monitored with the CLIF-C-ACLF calculator, which delivers grading for ACLF and estimates the risk of mortality, as the natural transplant-free course of ACLF is often fatal. Transplantation offers the best results in patients with ACLF that do not recover spontaneously. However, marginal donor organs should be avoided. Conclusion ACLF is an increasingly relevant indication with good outcome after liver transplantation. Adequate donor rates may reduce the incidence by means of timely transplantation of acute decompensated patients in lower stages of urgency. Future challenges comprise specific allocation of donor organs to this group of patients that are at a similar risk of mortality when compared to acute liver failure.
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Affiliation(s)
- Michael Heise
- Clinic for General and Visceral Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
| | - Nina Weiler
- Clinic for Medicine I, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
| | - Sonja Iken
- Clinic for Anesthesiology, Intensive Care and Pain Care, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
| | - Martin-Walter Welker
- Clinic for Medicine I, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
| | - Stefan Zeuzem
- Clinic for Medicine I, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
| | - Wolf O Bechstein
- Clinic for General and Visceral Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
| | - Andreas A Schnitzbauer
- Clinic for General and Visceral Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
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23
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Cascales-Campos PA, Ramírez P, González-Sánchez MR, Alconchel F, Martínez-Insfran LA, Sánchez-Bueno F, Robles R, Pons JA, Vargas Á, Sanmartín J, Royo-Villanova M, Parrilla P. Orthotopic Liver Transplantation With Elderly Donors (Over 80 Years of Age): A Prospective Evaluation. Transplant Proc 2018; 50:3594-3600. [PMID: 30577243 DOI: 10.1016/j.transproceed.2018.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/19/2018] [Accepted: 08/03/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Our main objective was to assess the clinical outcomes obtained in a single orthotopic liver transplant (OLT) hospital with donors ≥80 years of age compared to a control group of patients subjected to OLT during the same period of time with donors who were under 65 years of age. METHODS A prospective analysis was carried out on all the OLTs performed using liver grafts from donors in a state of brain death and with an age of ≥80 years (study group) between April 2007 and January 2015. The results of the study group (n = 36) were compared with those of a control group of patients less than 65 years of age receiving transplants with grafts. RESULTS A total of 51 potential donors ≥80 years were assessed, with a total of 36 liver transplants being carried out and their results were compared with a control group of 283 patients receiving transplants. The median follow-up time of the patients in the series was 36 months (range: 24-120 months). Graft survival at 1, 2, and 3 years was 77%, 72%, and 62%, respectively, among the patients in the study group and 79%, 73%, and 65% among the patients in the control group, and there were no statistically significant differences. Patient survival at 1, 2, and 3 years was 86%, 82%, and 75%, respectively, among the patients in the study group and 82%, 76%, and 72% among the patients in the control group, also without there being any statistically significant differences. CONCLUSIONS There is no age limit for liver transplant donors. The use of octogenarian donors makes it possible to increase the pool of donors while providing enough safety for the recipient.
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Affiliation(s)
- P A Cascales-Campos
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - P Ramírez
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - M R González-Sánchez
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - F Alconchel
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain.
| | - L A Martínez-Insfran
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - F Sánchez-Bueno
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - R Robles
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - J A Pons
- Department of Hepatology, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - Á Vargas
- Department of Hepatology, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - J Sanmartín
- Intensive Care Department, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - M Royo-Villanova
- Intensive Care Department, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
| | - P Parrilla
- Liver Transplantation Unit, Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca-IMIB Arrixaca, Murcia, Spain
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24
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Houben P, Hohenberger R, Yamanaka K, Büchler MW, Schemmer P. Evaluation of Graft Effluent High Mobility Group Box-1 (HMGB-1) for Prediction of Outcome After Liver Transplantation. Ann Transplant 2018; 23:475-480. [PMID: 30002362 PMCID: PMC6248035 DOI: 10.12659/aot.909165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 02/28/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Pre-transplant assessment of the graft for liver transplantation is crucial. Based on experimental data, this study was designed to assess both nuclear high mobility group box-1 (HMGB-1) protein and arginine-specific proteolytic activity (ASPA) in the graft effluent. MATERIAL AND METHODS In a non-interventional trial, both HMGB-1 and ASPA were measured in the effluent of 30 liver grafts after cold storage before transplantation. Values of HMGB-1 and ASPA levels were compared with established prognostic parameters such as the donor risk index, balance of risk score, and Donor-Model for End-Stage Liver Disease. RESULTS The early allograft dysfunction (EAD) was best predicted by recipient age (p=0.026) and HMGB-1 (p=0.031). HMGB -1 thresholds indicated the likelihood for initial non-function (1608 ng/ml, p=0.004) and EAD (580 ng/ml, p=0.017). The multivariate binary regression analysis showed a 21-fold higher (95% CI: 1.6-284.5, p=0.022) risk for EAD in cases with levels exceeding 580 ng/ml. The ASPA was lower in cases of initial non-function (p=0.028) but did not correlate with the rate of EAD (p=0.4). CONCLUSIONS This study demonstrates the feasibility of HMGB-1 detection in the graft effluent after cold storage. Along with conventional prognostic scores, it may be helpful to predict the early fate of a graft in human liver transplantation.
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25
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Badawy A, Kaido T, Hamaguchi Y, Anazawa T, Yagi S, Fukumitsu K, Kamo N, Okajima H, Uemoto S. Is Muscle MELD a More Promising Predictor for Mortality After Living Donor Liver Transplantation? Prog Transplant 2018; 28:213-219. [PMID: 29902957 DOI: 10.1177/1526924818781571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND To improve the outcome of living donor liver transplantation (LDLT), a scoring system that could predict accurately the patient and graft survival posttransplant is necessary. The aim of this study is to evaluate our previously proposed Muscle-model for end-stage liver disease (M-MELD) score and to compare it with the other available scores to find the best system that correlates with postoperative outcome after liver transplant. METHODS We retrospectively reviewed the data of 199 patients who underwent LDLT from January 2010 to July 2016 and calculated the preoperative MELD, MELD Na, the product of donor age and MELD (D-MELD), M-MELD, integrated MELD, and the balance of risk (BAR) score in all patients. The area under the receiver operating characteristics curves (AUCs) of each score was computed and compared at 3-, 6-months, and 1-year after LDLT. RESULTS The M-MELD, D-MELD, and integrated MELD had a good discriminative performance in predicting 3-month mortality after LDLT with AUCs > 0.7, while the M-MELD was the only score that showed a good discriminative performance in predicting 6-month and 1-year mortality after LDLT with AUCs > 0.7. CONCLUSION Muscle-MELD score is a simple and useful predictor of patient survival after LDLT which showed a better predictive performance than other available scores.
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Affiliation(s)
- Amr Badawy
- 1 Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University, Kyoto, Japan.,2 Department of General Surgery, Alexandria University, Alexandria, Egypt
| | - Toshimi Kaido
- 1 Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University, Kyoto, Japan
| | - Yuhei Hamaguchi
- 1 Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University, Kyoto, Japan
| | - Takayuki Anazawa
- 1 Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University, Kyoto, Japan
| | - Shintaro Yagi
- 1 Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University, Kyoto, Japan
| | - Ken Fukumitsu
- 1 Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University, Kyoto, Japan
| | - Naoko Kamo
- 1 Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- 1 Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- 1 Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University, Kyoto, Japan
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26
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Serper M, Bittermann T, Rossi M, Goldberg DS, Thomasson AM, Olthoff KM, Shaked A. Functional status, healthcare utilization, and the costs of liver transplantation. Am J Transplant 2018; 18:1187-1196. [PMID: 29116679 DOI: 10.1111/ajt.14576] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 10/30/2017] [Accepted: 10/30/2017] [Indexed: 01/25/2023]
Abstract
The Model for End-Stage Liver Disease (MELD) score predicts higher transplant healthcare utilization and costs; however, the independent contribution of functional status towards costs is understudied. The study objective was to evaluate the association between functional status, as measured by Karnofsky Performance Status (KPS), and liver transplant (LT) costs in the first posttransplant year. In a cohort of 598 LT recipients from July 1, 2009 to November 30, 2014, multivariable models assessed associations between KPS and outcomes. LT recipients needing full assistance (KPS 10%-40%) vs being independent (KPS 80%-100%) were more likely to be discharged to a rehabilitation facility after LT (22% vs 3%) and be rehospitalized within the first posttransplant year (78% vs 57%), all P < .001. In adjusted generalized linear models, in addition to MELD (P < .001), factors independently associated with higher 1-year post-LT transplant costs were older age, poor functional status (KPS 10%-40%), living donor LT, pre-LT hemodialysis, and the donor risk index (all P < .001). One-year survival for patients in the top cost decile was 83% vs 93% for the rest of the cohort (log rank P < .001). Functional status is an important determinant of posttransplant resource utilization; therefore, standardized measurements of functional status should be considered to optimize candidate selection and outcomes.
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Affiliation(s)
- Marina Serper
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Therese Bittermann
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Rossi
- Corporate Finance, Decision Support & Reimbursement, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - David S Goldberg
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Arwin M Thomasson
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kim M Olthoff
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Abraham Shaked
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA, USA
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27
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Szilágyi ÁL, Mátrai P, Hegyi P, Tuboly E, Pécz D, Garami A, Solymár M, Pétervári E, Balaskó M, Veres G, Czopf L, Wobbe B, Szabó D, Wagner J, Hartmann P. Compared efficacy of preservation solutions on the outcome of liver transplantation: Meta-analysis. World J Gastroenterol 2018; 24:1812-1824. [PMID: 29713134 PMCID: PMC5922999 DOI: 10.3748/wjg.v24.i16.1812] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/02/2018] [Accepted: 04/09/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the effects of the four most commonly used preservation solutions on the outcome of liver transplantations. METHODS A systematic literature search was performed using MEDLINE, Scopus, EMBASE and the Cochrane Library databases up to January 31st, 2017. The inclusion criteria were comparative, randomized controlled trials (RCTs) for deceased donor liver (DDL) allografts with adult and pediatric donors using the gold standard University of Wisconsin (UW) solution or histidine-tryptophan-ketoglutarate (HTK), Celsior (CS) and Institut Georges Lopez (IGL-1) solutions. Fifteen RCTs (1830 livers) were included; the primary outcomes were primary non-function (PNF) and one-year post-transplant graft survival (OGS-1). RESULTS All trials were homogenous with respect to donor and recipient characteristics. There was no statistical difference in the incidence of PNF with the use of UW, HTK, CS and IGL-1 (RR = 0.02, 95%CI: 0.01-0.03, P = 0.356). Comparing OGS-1 also failed to reveal any difference between UW, HTK, CS and IGL-1 (RR = 0.80, 95%CI: 0.80-0.80, P = 0.369). Two trials demonstrated higher PNF levels for UW in comparison with the HTK group, and individual studies described higher rates of biliary complications where HTK and CS were used compared to the UW and IGL-1 solutions. However, the meta-analysis of the data did not prove a statistically significant difference: the UW, CS, HTK and IGL-1 solutions were associated with nearly equivalent outcomes. CONCLUSION Alternative solutions for UW yield the same degree of safety and effectiveness for the preservation of DDLs, but further well-designed clinical trials are warranted.
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Affiliation(s)
| | - Péter Mátrai
- Institute of Bioanalysis, University of Pécs, Pécs H-7624, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine and First Department of Medicine, University of Pécs, Pécs H-7624, Hungary
- MTA-SZTE Translational Gastroenterology Research Group, Szeged H-6720, Hungary
- János Szentágothai Research Center, University of Pécs, Pécs H-7624, Hungary
| | - Eszter Tuboly
- Institute of Surgical Research, University of Szeged, Szeged H-6720, Hungary
| | - Daniella Pécz
- Institute of Surgical Research, University of Szeged, Szeged H-6720, Hungary
| | - András Garami
- Institute for Translational Medicine and First Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Margit Solymár
- Institute for Translational Medicine and First Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Erika Pétervári
- Institute for Translational Medicine and First Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Márta Balaskó
- Institute for Translational Medicine and First Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Gábor Veres
- 1st Department of Paediatrics, University of Semmelweis, Budapest H-1085, Hungary
| | - László Czopf
- Department of Cardiology, 1st Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Bastian Wobbe
- Department of Cardiology, 1st Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Dorottya Szabó
- Department of Cardiology, 1st Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Juliane Wagner
- Department of Cardiology, 1st Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Petra Hartmann
- Institute of Surgical Research, University of Szeged, Szeged H-6720, Hungary
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Hamaguchi Y, Kaido T, Okumura S, Kobayashi A, Shirai H, Yao S, Yagi S, Kamo N, Okajima H, Uemoto S. Proposal for new selection criteria considering pre-transplant muscularity and visceral adiposity in living donor liver transplantation. J Cachexia Sarcopenia Muscle 2018; 9:246-254. [PMID: 29453829 PMCID: PMC5879966 DOI: 10.1002/jcsm.12276] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 10/18/2017] [Accepted: 11/20/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The significance of pre-operative body composition has recently attracted much attention in various diseases. However, cut-off values for these parameters remain undetermined, and these factors are not currently included in selection criteria for recipients of living donor liver transplantation (LDLT). METHODS Using computed tomography of 657 donors for LDLT, skeletal muscle mass, muscle quality, and visceral adiposity were evaluated by using skeletal muscle mass index (SMI), intramuscular adipose tissue content (IMAC), and visceral-to-subcutaneous adipose tissue area ratio (VSR). Sex-specific cut-offs for SMI, IMAC, and VSR were determined, and correlations with outcomes after LDLT in 277 recipients were examined with the aim of establishing new selection criteria for LDLT. RESULTS On the basis of younger donor data, we determined sex-specific cut-off values for low SMI, high IMAC, and high VSR (mean ± 2 standard deviations). Patients with all three factors showed the lowest survival rate after LDLT (1 year survival rate, 41.2%; P < 0.001). On multivariate analysis, low SMI (P = 0.002), high IMAC (P = 0.002), and high VSR (P = 0.001) were identified as independent risk factors for mortality after LDLT. Based on these findings, we have excluded patients showing all three factors (low SMI, high IMAC, and high VSR) as candidates for LDLT since October 2016. CONCLUSIONS Using cut-off values determined from healthy donors, we have established new selection criteria for LDLT including body composition, which should improve post-transplant outcomes.
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Affiliation(s)
- Yuhei Hamaguchi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshimi Kaido
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinya Okumura
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Kobayashi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hisaya Shirai
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Siyuan Yao
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shintaro Yagi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Naoko Kamo
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Englschalk C, Eser D, Jox RJ, Gerbes A, Frey L, Dubay DA, Angele M, Stangl M, Meiser B, Werner J, Guba M. Benefit in liver transplantation: a survey among medical staff, patients, medical students and non-medical university staff and students. BMC Med Ethics 2018; 19:7. [PMID: 29433496 PMCID: PMC5810023 DOI: 10.1186/s12910-018-0248-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 01/29/2018] [Indexed: 12/23/2022] Open
Abstract
Background The allocation of any scarce health care resource, especially a lifesaving resource, can create profound ethical and legal challenges. Liver transplant allocation currently is based upon urgency, a sickest-first approach, and does not utilize capacity to benefit. While urgency can be described reasonably well with the MELD system, benefit encompasses multiple dimensions of patients’ well-being. Currently, the balance between both principles is ill-defined. Methods This survey with 502 participants examines how urgency and benefit are weighted by different stakeholders (medical staff, patients on the liver transplant list or already transplanted, medical students and non-medical university staff and students). Results Liver transplant patients favored the sickest-first allocation, although all other groups tended to favor benefit. Criteria of a successful transplantation were a minimum survival of at least 1 year and recovery of functional status to being ambulatory and capable of all self-care (ECOG 2). An individual delisting decision was accepted when the 1-year survival probability would fall below 50%. Benefit was found to be a critical variable that may also trigger the willingness to donate organs. Conclusions The strong interest of stakeholder for successful liver transplants is inadequately translated into current allocation rules.
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Affiliation(s)
- Christine Englschalk
- Department of General, Visceral, Vascular and Transplant Surgery, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Daniela Eser
- Department of Psychiatry and Psychotherapy, Klinikum der Universität München, Nußbaumstraße 7, 80336, München, Germany
| | - Ralf J Jox
- Institute of Ethics, History and Theory of Medicine, LMU Munich, Lessingstr. 2, 80336, München, Germany
| | - Alexander Gerbes
- Department of Medicine II, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Lorenz Frey
- Department of Anesthesiology, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Derek A Dubay
- Department of Surgery, Division of Transplant Surgery, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Martin Angele
- Department of General, Visceral, Vascular and Transplant Surgery, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Manfred Stangl
- Department of General, Visceral, Vascular and Transplant Surgery, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Bruno Meiser
- Transplant Center Munich, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Jens Werner
- Department of General, Visceral, Vascular and Transplant Surgery, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Markus Guba
- Department of General, Visceral, Vascular and Transplant Surgery, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany. .,Transplant Center Munich, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany.
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Fukazawa K, Pretto EA, Nishida S, Reyes JD, Gologorsky E. Factors associated with mortality within 24 h of liver transplantation: An updated analysis of 65,308 adult liver transplant recipients between 2002 and 2013. J Clin Anesth 2018; 44:35-40. [DOI: 10.1016/j.jclinane.2017.10.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/19/2017] [Accepted: 10/20/2017] [Indexed: 02/07/2023]
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Karlsen TH, Folseraas T, Thorburn D, Vesterhus M. Primary sclerosing cholangitis - a comprehensive review. J Hepatol 2017; 67:1298-1323. [PMID: 28802875 DOI: 10.1016/j.jhep.2017.07.022] [Citation(s) in RCA: 486] [Impact Index Per Article: 69.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 07/15/2017] [Accepted: 07/22/2017] [Indexed: 02/07/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a rare disorder characterised by multi-focal bile duct strictures and progressive liver disease. Inflammatory bowel disease is usually present and there is a high risk of cholangiocarcinoma and colorectal cancer. Most patients ultimately require liver transplantation, after which disease recurrence may occur. With limited therapeutic options and a lack of proven surveillance strategies, patients currently have significant unmet needs. In the present seminar, we provide a comprehensive review of the status of the field. We emphasise developments related to patient stratification and disease behaviour, and provide an overview of management options from a practical, patient-centered perspective. We survey advances made in the understanding of PSC pathogenesis and summarise the ongoing efforts to develop an effective therapy based on these insights.
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Affiliation(s)
- Tom H Karlsen
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Norway; Research Institute of Internal Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.
| | - Trine Folseraas
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway; Research Institute of Internal Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Douglas Thorburn
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London, UK; Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Mette Vesterhus
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway; National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
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32
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Umgelter A, Hapfelmeier A, Kopp W, van Rosmalen M, Rogiers X, Guba M. Disparities in Eurotransplant liver transplantation wait-list outcome between patients with and without model for end-stage liver disease exceptions. Liver Transpl 2017. [PMID: 28650098 DOI: 10.1002/lt.24805] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The sickest-first principle in donor-liver allocation can be implemented by allocating organs to patients with cirrhosis with the highest Model for End-Stage Liver Disease (MELD) scores. For patients with other risk factors, standard exceptions (SEs) and nonstandard exceptions (NSEs) have been developed. We investigated whether this system of matched MELD scores achieves similar outcomes on the liver transplant waiting list for various diagnostic groups in Eurotransplant (ET) countries with MELD-based individual allocation (Belgium, the Netherlands, and Germany). A retrospective analysis of the ET wait-list outflow from December 2006 until December 2015 was conducted to investigate the relation of the unified MELD-based allocation to the risk of a negative wait-list outcome (death on the waiting list or delisting as too sick) as opposed to a positive wait-list outcome (transplantation or delisting as recovered). A total of 16,926 patients left the waiting list with a positive (11,580) or negative (5346) outcome; 3548 patients had a SE, and 330 had a NSE. A negative outcome was more common among patients without a SE or NSE (34.3%) than among patients with a SE (22.6%) or NSE (18.6%; P < 0.001). Analysis by model-based recursive partitioning detected 5 risk groups with different relations of matched MELD to a negative outcome. In Germany, we found the following: (1) no SE or NSE, SE for biliary sepsis (BS); (2) SE for hepatocellular carcinoma (HCC), hepatopulmonary syndrome (HPS), or portopulmonary hypertension (PPH); and (3) SE for primary sclerosing cholangitis (PSC) or polycystic liver disease (PcLD). In Belgium and the Netherlands, we found the following: (4) SE or NSE, or SE for HPS or PPH; and (5) SE for BS, HCC, PcLD, or PSC. In conclusion, SEs and NSEs do not even out risks across different diagnostic groups. Patients with SEs or NSEs appear advantaged toward patients with cirrhosis without SEs or NSEs. Liver Transplantation 23 1256-1265 2017 AASLD.
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Affiliation(s)
- Andreas Umgelter
- 2nd Medical Department, Technische Universität München, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Statistics and Epidemiology, Technische Universität München, Munich, Germany
| | - Wouter Kopp
- Eurotransplant International Foundation, Leiden, the Netherlands
| | | | - Xavier Rogiers
- Department of Surgery, Gent University Hospital Medical School, Gent, Belgium
| | - Markus Guba
- Department of General, Visceral and Transplant Surgery, Großhadern Clinic, University of Munich, Munich, Germany
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33
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Gustot T, Agarwal B. Selected patients with acute-on-chronic liver failure grade 3 are not too sick to be considered for liver transplantation. J Hepatol 2017; 67:667-668. [PMID: 28923205 DOI: 10.1016/j.jhep.2017.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 07/21/2017] [Accepted: 07/21/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Thierry Gustot
- Dept. Gastroenterology and Hepato-Pancreatology, C.U.B. Erasme Hospital, Brussels, Belgium; Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium; Inserm Unité 1149, Centre de Recherche sur l'inflammation (CRI), Paris, France; UMR S_1149, Université Paris Diderot, Paris, France; The EASL-CLIF Consortium, European Foundation-CLIF, Barcelona, Spain.
| | - Banwari Agarwal
- Intensive Care Unit, Royal Free Hospital, London, UK; Institute for Liver and Digestive Health, University College London, Royal Free Campus, UK
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Abstract
Liver allocation in Eurotransplant is complex because allocation rules need to follow not only the guidelines of the European Commission but also the specific regulations of each of the 7 Eurotransplant countries with active liver transplant programs. Thirty-eight liver transplant centers served a population of about 135 million in 2015. Around 1600 deceased donor livers are transplanted annually. The number of deceased organ donors remains stable but donor age is increasing. Nevertheless, liver utilization rates are unchanged at around 80%. Donation after circulatory determination of death (DCD) increased fourfold in the past decade. In Belgium and the Netherlands, DCDs were responsible for 30% of deceased donor liver transplant activity in 2015; Austria only occasionally transplants a DCD liver; other Eurotransplant countries do not have active DCD programs. The most frequent indications for liver transplantation are alcoholic liver disease, hepatocellular carcinoma, and viral hepatitis. Livers are allocated first internationally to high urgency status patients or those with an approved combined organ status (for a liver in combination with heart, lung, intestine, or pancreas) and then on a national basis where allocation is recipient-driven or center-driven, depending on country-specific rules. Median waiting time for an elective liver transplant was 4,4 months in 2015; high urgency status patients waited a median of 2 days for a suitable liver. Mortality on the waiting list was 18% in 2015, 4% of patients were delisted because they became unfit for transplantation. One-year and 5-year risk unadjusted adult patient survival after transplantation is 80% and 65%, respectively.
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35
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Schrem H, Volz S, Koch HF, Gwiasda J, Kürsch P, Goldis A, Pöhnert D, Winny M, Klempnauer J, Kaltenborn A. Statistical approach to quality assessment in liver transplantation. Langenbecks Arch Surg 2017; 403:61-71. [DOI: 10.1007/s00423-017-1612-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 07/24/2017] [Indexed: 01/07/2023]
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36
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Actual Risk of Using Very Aged Donors for Unselected Liver Transplant Candidates: A European Single-center Experience in the MELD Era. Ann Surg 2017; 265:388-396. [PMID: 28059967 DOI: 10.1097/sla.0000000000001681] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the whole experience of liver transplantation (LT) with donors ≥70 years in a single center not applying specific donor/recipient matching criteria. BACKGROUND LT with very old donors has historically been associated with poorer outcomes. With the increasing average donor age and the advent of Model for End-stage Liver Diseases (MELD) score-based allocation criteria, an optimal donor/recipient matching is often unsuitable. METHODS Outcomes of all types of LTs were compared according to 4 study groups: patients transplanted between 1998 and 2003 with donors <70 (group 1, n = 396) or ≥70 years (group 2, n = 88); patients transplanted between 2004 and 2010 with donors <70 (group 3, n = 409), or ≥70 years (group 4, n = 190). From 2003, graft histology was routinely available before cross-clamping, and MELD-driven allocation was adopted. RESULTS Groups 1 and 2 were similar for main donor and recipient variables, and surgical details. Group 4 had shorter donor ICU stay, lower rate of moderate-to-severe graft macrosteatosis (2.3% vs 8%), and higher recipient MELD score (22 vs 19) versus group 3. After 2003, median donor age, recipient age, and MELD score significantly increased, whereas moderate-to-severe macrosteatosis and ischemia time decreased. Five-year graft survival was 63.6% in group 1 versus 59.1% in group 2 (P = 0.252) and 70.9% in group 3 versus 67.6% in group 4 (P = 0.129). Transplants performed between 1998 and 2003, recipient HCV infection, balance of risk score >18, and pre-LT renal replacement treatments were independently associated with worse graft survival. CONCLUSIONS Even without specific donor/recipient matching criteria, the outcomes of LT with donors ≥70 and <70 years are comparable with appropriate donor management.
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37
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Bertuzzo VR, Giannella M, Cucchetti A, Pinna AD, Grossi A, Ravaioli M, Del Gaudio M, Cristini F, Viale P, Cescon M. Impact of preoperative infection on outcome after liver transplantation. Br J Surg 2017; 104:e172-e181. [PMID: 28121031 DOI: 10.1002/bjs.10449] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/28/2016] [Accepted: 11/03/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bacterial infection in patients with liver failure can lead to a dramatic clinical deterioration. The indications for liver transplantation and outcome in these patients is still controversial. METHODS All adult patients who underwent liver transplantation between 1 January 2010 and 31 December 2015 were selected from an institutional database. Characteristics of the donors and recipients, and clinical, biochemical and surgical parameters were retrieved from the database. Post-transplant survival rates and complications, including grade III-IV complications according to the Dindo-Clavien classification, were compared between patients with an infection 1 month before transplantation and patients without an infection. RESULTS Eighty-four patients with an infection had statistically significant higher Model for End-stage Liver Disease (MELD), D-MELD and Balance of Risk (BAR) scores and a higher rate of acute-on-chronic liver failure compared with findings in 343 patients with no infection. The rate of infection after liver transplantation was higher in patients who had an infection before the operation: 48 per cent versus 30·6 per cent in those with no infection before transplantation (P = 0·003). The percentage of patients with a postoperative complication (42 versus 40·5 per cent respectively; P = 0·849) and the 90-day mortality rate (8 versus 6·4 per cent; P = 0·531) was no different between the groups. Multivariable analysis showed that a BAR score greater than 18 and acute-on-chronic liver failure were independent predictors of 90-day mortality. CONCLUSION Bacterial infection 1 month before liver transplantation is related to a higher rate of infection after transplantation, but does not lead to a worse outcome.
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Affiliation(s)
- V R Bertuzzo
- General and Transplant Surgery Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - M Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - A Cucchetti
- General and Transplant Surgery Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - A D Pinna
- General and Transplant Surgery Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - A Grossi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - M Ravaioli
- General and Transplant Surgery Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - M Del Gaudio
- General and Transplant Surgery Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - F Cristini
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - P Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - M Cescon
- General and Transplant Surgery Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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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.
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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
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A good prognostic predictor for liver transplantation recipients with benign end-stage liver cirrhosis. Hepatobiliary Pancreat Dis Int 2017; 16:164-168. [PMID: 28381380 DOI: 10.1016/s1499-3872(16)60187-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Post-transplant model for predicting mortality (PMPM, calculated as -5.359+1.988Xln (serum creatinine [mg/dL])+1.089Xln (total bilirubin [mg/dL])) score has been proved to be a simple and accurate model for predicting the prognosis after liver transplantation (LT) in a single center study. Here we aim to verify this model in a large cohort of patients. METHODS A total of 2727 patients undergoing LT with end-stage liver cirrhosis from January 2003 to December 2010 were included in this retrospective study. Data were collected from the China Liver Transplant Registry (CLTR). PMPM score was calculated at 24-h and 7-d following LT. According to the PMPM score at 24-h, all patients were divided into the low-risk group (PMPM score ≤-1.4, n=2509) and the high-risk group (PMPM score >-1.4, n=218). The area under receiver operator characteristic curve (AUROC) was calculated for evaluating the prognostic accuracy. RESULTS The 1-, 3-, and 5-year patient survival rates in the low-risk group were significantly higher than those in the high-risk group (90.23%, 88.01%, and 86.03% vs 63.16%, 59.62%, and 56.43%, respectively, P<0.001). In the high-risk group, 131 patients had a decreased PMPM score (≤-1.4) at 7-d, and their cumulative survival rate was significantly higher than the other 87 patients with sustained high PMPM score (>-1.4) (P<0.001). For predicting 3-month mortality, PMPM score showed a much higher AUROC than post-transplant MELD score (P<0.05). CONCLUSION PMPM score is a simple and effective tool to predict short-term mortality after liver transplantation in patients with benign liver diseases, and an indicator for prompt salvaging treatment as well.
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Stratigopoulou P, Paul A, Hoyer DP, Kykalos S, Saner FH, Sotiropoulos GC. High MELD score and extended operating time predict prolonged initial ICU stay after liver transplantation and influence the outcome. PLoS One 2017; 12:e0174173. [PMID: 28319169 PMCID: PMC5358862 DOI: 10.1371/journal.pone.0174173] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 03/03/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The aim of the present study is to determine the incidence of a prolonged (>3 days) initial ICU-stay after liver transplantation (LT) and to identify risk factors for it. PATIENTS AND METHODS We retrospectively analyzed data of adult recipients who underwent deceased donor first-LT at the University Hospital Essen between 11/2003 and 07/2012 and showed a primary graft function. RESULTS Of the 374 recipients, 225 (60.16%) had prolonged ICU-stay. On univariate analysis, donor INR, high doses of vasopressors, "rescue-offer" grafts, being hospitalized at transplant, high urgency cases, labMELD, alcoholic cirrhosis, being on renal dialysis and length of surgery were associated with prolonged ICU-stay. After multivariate analysis, only the labMELD and the operation's length were independently correlated with prolonged ICU-stay. Cut-off values for these variables were 19 and 293.5 min, respectively. Hospital stay was longer for patients with a prolonged initial ICU-stay (p<0.001). Survival rates differed significantly between the two groups at 3 months, 1-year and 5-years after LT (p<0.001). CONCLUSIONS LabMELD and duration of LT were identified as independent predictors for prolonged ICU-stay after LT. Identification of recipients in need of longer ICU-stay could contribute to a more evidenced-based and cost-effective use of ICU facilities in transplant centers.
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Affiliation(s)
- Panagiota Stratigopoulou
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
| | - Dieter P. Hoyer
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
| | - Stylianos Kykalos
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
- * E-mail:
| | - Fuat H. Saner
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
| | - Georgios C. Sotiropoulos
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
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One More Step Toward a Clinically Applicable Tolerance Induction Protocol in Solid Organ Transplantation? Transplantation 2017; 101:902-903. [PMID: 28252559 DOI: 10.1097/tp.0000000000001712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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42
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Putignano A, Gustot T. New concepts in acute-on-chronic liver failure: Implications for liver transplantation. Liver Transpl 2017; 23:234-243. [PMID: 27750389 DOI: 10.1002/lt.24654] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 09/22/2016] [Accepted: 09/30/2016] [Indexed: 02/07/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a recently defined syndrome that occurs frequently in patients with cirrhosis and is associated with a poor short-term prognosis. Currently, management of patients with ACLF is mainly supportive. Despite medical progress, this syndrome frequently leads to multiorgan failure, sepsis, and, ultimately, death. The results of attempts to use liver transplantation (LT) to manage this critical condition have been poorly reported but are promising. Currently, selection criteria of ACLF patients for LT, instructions for prioritization on the waiting list, and objective indicators for removal of ACLF patients from the waiting list in cases of clinical deterioration are poorly defined. Before potential changes can be implemented into decisional algorithms, their effects, either on the benefits to individual patients or on global transplant outcomes, should be carefully evaluated using objective longterm endpoints that take into account ethical considerations concerning LT. Liver Transplantation 23 234-243 2017 AASLD.
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Affiliation(s)
- Antonella Putignano
- Department of Gastroenterology and Hepato-Pancreatology, C.U.B. Erasme Hospital, Brussels, Belgium
| | - Thierry Gustot
- Department of Gastroenterology and Hepato-Pancreatology, C.U.B. Erasme Hospital, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium.,INSERM Unité 1149, Centre de Recherche sur l'inflammation, Paris, France.,Unités Mixtes de Recherche en Santé 1149, Université Paris Diderot, Paris, France
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Saldaña RS, Schrem H, Barthold M, Kaltenborn A. Prognostic Abilities and Quality Assessment of Models for the Prediction of 90-Day Mortality in Liver Transplant Waiting List Patients. PLoS One 2017; 12:e0170499. [PMID: 28129338 PMCID: PMC5271345 DOI: 10.1371/journal.pone.0170499] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/01/2016] [Indexed: 12/28/2022] Open
Abstract
Background Model of end-stage liver disease (MELD)-score and diverse variants are widely used for prognosis on liver transplant waiting-lists. Methods 818 consecutive patients on the liver transplant waiting-list included to calculate the MELD, MESO Index, MELD-Na, UKELD, iMELD, refitMELD, refitMELD-Na, upMELD and PELD-scores. Prognostic abilities for 90-day mortality were investigated applying Receiver-operating-characteristic-curve analysis. Independent risk factors for 90-day mortality were identified with multivariable binary logistic regression modelling. Methodological quality of the underlying development studies was assessed with a systematic assessment tool. Results 74 patients (9%) died on the liver transplant waiting list within 90 days after listing. All but one scores, refitMELD-Na, had acceptable prognostic performance with areas under the ROC-curves (AUROCs)>0.700. The iMELD performed best (AUROC = 0.798). In pediatric cases, the PELD-score just failed to reach the acceptable threshold with an AUROC = 0.699. All scores reached a mean quality score of 72.3%. Highest quality scores could be achieved by the UKELD and PELD-scores. Studies specifically lack statistical validity and model evaluation. Conclusions Inferior quality assessment of prognostic models does not necessarily imply inferior prognostic abilities. The iMELD might be a more reliable tool representing urgency of transplantation than the MELD-score. PELD-score is assumedly not accurate enough to allow graft allocation decision in pediatric liver transplantation.
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Affiliation(s)
- Ricardo Salinas Saldaña
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Harald Schrem
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Marc Barthold
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Alexander Kaltenborn
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- Department of Trauma and Orthopedic Surgery, Federal Armed Forces Hospital Westerstede, Westerstede, Germany
- * E-mail:
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McCaughan GW, Crawford M, Sandroussi C, Koorey DJ, Bowen DG, Shackel NA, Strasser SI. Assessment of adult patients with chronic liver failure for liver transplantation in 2015: who and when? Intern Med J 2017; 46:404-12. [PMID: 27062203 DOI: 10.1111/imj.13025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 12/06/2015] [Accepted: 12/07/2015] [Indexed: 02/06/2023]
Abstract
In 2015, there are a few absolute contraindications to liver transplantation. In adult patients, survival post-liver transplant is excellent, with 1-year survival rate >90% and 5-year survival rates >80% and predicted median allograft survival beyond 20 years. Patients with a Child-Turcotte Pugh score ≥9 or a model for end-stage liver disease (MELD) score >15 should be referred for liver transplantation, with patients who have a MELD score >17 showing a 1-year survival benefit with liver transplantation. A careful selection of hepatocellular cancer patients results in excellent outcomes, while consideration of extra-hepatic disease (reversible vs irreversible) and social support structures are crucial to patient assessment. Alcoholic liver disease remains a challenge, and the potential to cure hepatitis C virus infection together with the emerging issue of non-alcoholic fatty liver disease-associated chronic liver failure will change the landscape of the who in the years ahead. The when will continue to be determined largely by the severity of liver disease based on the MELD score for the foreseeable future.
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Affiliation(s)
- G W McCaughan
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Liver Injury and Cancer Group, Centenary Institute, University of Sydney, Sydney, New South Wales, Australia
| | - M Crawford
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - C Sandroussi
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - D J Koorey
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - D G Bowen
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Liver Injury and Cancer Group, Centenary Institute, University of Sydney, Sydney, New South Wales, Australia
| | - N A Shackel
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Liver Injury and Cancer Group, Centenary Institute, University of Sydney, Sydney, New South Wales, Australia
| | - S I Strasser
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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46
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Dutkowski P, Clavien PA. Scorecard and insights from approaches to liver allocation around the world. Liver Transpl 2016; 22:9-13. [PMID: 27600724 DOI: 10.1002/lt.24631] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 08/30/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Phillip Dutkowski
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Pierre A Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
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Hamaguchi Y, Kaido T, Okumura S, Kobayashi A, Shirai H, Yagi S, Hammad A, Okajima H, Uemoto S. Proposal of Muscle-MELD Score, Including Muscularity, for Prediction of Mortality After Living Donor Liver Transplantation. Transplantation 2016; 100:2416-2423. [DOI: 10.1097/tp.0000000000001413] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Sotiropoulos GC, Vernadakis S, Paul A, Hoyer DP, Saner FH, Gallinat A. Single-Center Experience on Liver Transplantation for Model for End-Stage Liver Disease Score 40 Patients. Dig Dis Sci 2016; 61:3346-3353. [PMID: 27538409 DOI: 10.1007/s10620-016-4274-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 08/08/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Organ shortage and waiting list mortality have led to changes in the allocation policy in Eurotransplant. AIM To identify factors influencing the survival of liver transplanted patients with model for end-stage liver disease (MELD) score of 40. PATIENTS AND METHODS Data of listed adult patients who reached a MELD score 40 in the period 12/2006-06/2010 were reviewed. Donor/graft and recipient characteristics, and operative details were analyzed. Statistical analysis encompassed Kaplan-Meier analysis/log-rank test as well as univariate and multivariable regression analyses. RESULTS Forty-eight patients achieved a MELD score 40. Thirty patients were transplanted, whereas 18 patients were not. Three-month, 1-year, and 5-year patient and graft survival for transplanted patients was 53, 50, and 47 %, respectively. Three-month and 1-year survival after listing was 11 and 6 % for not transplanted patients, respectively (p < 0.0001). Multivariable analysis revealed pre-operative dialysis (p = 0.0246) and portal vein thrombosis (PVT) (p = 0.0231) to be independent prognostic factors for post-transplant patient survival. A point scoring system was created, which reached statistical significance (p = 0.0007). One-year and 5-year survival for scores 0, 1, and 2 were 72 and 64, 42 and 42 and 0 %, respectively. There was no statistical difference in transplantation costs between patients who survived or died (p = 0.1578). CONCLUSIONS At our center, coexistence of pre-operative dialysis and PVT represents a clear contraindication for LT regarding MELD score 40 patients.
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Affiliation(s)
- Georgios C Sotiropoulos
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany.
| | - Spyridon Vernadakis
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Dieter P Hoyer
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Fuat H Saner
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Anja Gallinat
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
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Strassburg CP. HCC-Associated Liver Transplantation - Where Are the Limits and What Are the New Regulations? Visc Med 2016; 32:263-271. [PMID: 27722163 DOI: 10.1159/000446385] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) represents an increasing health burden worldwide and a challenging disease both in terms of diagnosis and treatment. METHODS The literature available on PubMed for the period of 1990-2016 was reviewed with reference to liver allocation, HCC, liver transplantation (LT), and prediction, and the allocation rules of the German Transplant Act were reviewed. RESULTS Due to etiological and geographical diversity, HCC is not a homogeneous disease. In the vast majority of patients, HCC develops as a complication of chronic liver disease and cirrhosis. While most patients present with advanced HCC for which palliative strategies are the only available option, LT is the best treatment approach as it not only eliminates the diseased liver and the underlying hepatocarcinogenic mechanisms but also the cancer. The decision for LT is not an easy one to make, because outcome prediction, staging, bridging therapy, and recurrence prevention are difficult and are estimated against the background of the scarce resource of donor organs which are also competitively sought after by patients suffering from non-neoplastic terminal liver diseases, raising the issue of equality of chances in a rationed therapeutic modality. Currently, the Milan criteria are the best evaluated decision tool for LT, but many issues such as down-staging, favorable biological behavior during treatment, expansion of the morphological classification, molecular predictors, and individualized approaches are not yet satisfactorily addressed. CONCLUSION In order to provide a fair and effective approach to LT in HCC, the employed allocation rules require continuous development and scientific evaluation. Recently, the allocation rules for standard exception priority according to the German Transplant Act have been revised to improve patient selection for LT in HCC.
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Lauerer M, Kaiser K, Nagel E. Organ Transplantation in the Face of Donor Shortage - Ethical Implications with a Focus on Liver Allocation. Visc Med 2016; 32:278-285. [PMID: 27722165 DOI: 10.1159/000446382] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Transplantation medicine is associated with several ethical issues related to the lack of organs. Major questions concern the regulations for giving permission for organ removal, informing the public about organ donation, setting of organ allocation priorities, waiting list access, and strategies to counteract scarcity. METHODS This contribution is based on analyses of legal regulations, guidelines of self-regulatory bodies, administrative data, and literature from medical, normative, and empiric disciplines. It addresses the above-mentioned issues descriptively with a focus on Germany and liver transplantation. RESULTS The basic principle of beneficence justifies a shift from voluntariness towards an obligation to document one's decision regarding organ donation. Organ allocation is obviously tangent to fundamental values and concepts of justice. At that, there is no consistent agreement on whether to prioritize the sickest patient or to maximize the overall health benefit. Restrictions relating to waiting list access are the subject of controversies. The reasons for denial of access are largely related to high demands on the prospect of success. Strategies to counteract organ scarcity partly conflict with the respect for autonomy, non-maleficence, beneficence, or justice. CONCLUSION We propose to focus on recent most promising strategies to counteract scarcity in the short-term: demanding a documented decision on organ donation and an orientation towards the Spanish model of organization. Concepts for waiting list access should constantly be reviewed considering all medical evidence and must not be based on moralism. Moreover, we suggest to consider public preferences for organ allocation and strengthen the confidence in transplantation medicine.
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Affiliation(s)
- Michael Lauerer
- Institut für Medizinmanagement und Gesundheitswissenschaften, Universität Bayreuth, Bayreuth, Germany
| | - Katharina Kaiser
- Institut für Medizinmanagement und Gesundheitswissenschaften, Universität Bayreuth, Bayreuth, Germany
| | - Eckhard Nagel
- Institut für Medizinmanagement und Gesundheitswissenschaften, Universität Bayreuth, Bayreuth, Germany
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