Karnofsky performance status before and after liver transplantation predicts graft and patient survival

Clinical Characteristics Associated With Posttransplant Survival Among Adults 70 Years Old or Older Undergoing Liver Transplantation

GOALS

We sought to identify pre-liver transplantation (LT) characteristics among older adults associated with post-LT survival.

BACKGROUND

The proportion of older patients undergoing deceased-donor liver transplantation (DDLT) has increased over time.

STUDY

We analyzed adult DDLT recipients in the United Network for Organ Sharing registry from 2016 through 2020, excluding patients listed as status 1 or with a model of end-stage liver disease exceptions for hepatocellular carcinoma. Kaplan-Meier methods were used to estimate post-LT survival probabilities among older recipients (age ≥70 y). Associations between clinical covariates and post-LT mortality were assessed using Cox regressions.

RESULTS

Of 22,862 DDLT recipients, 897 (4%) were 70 years old or older. Compared with younger recipients, older recipients had worse overall survival ( P < 0.01) (1 y: 88% vs 92%, 3 y: 77% vs 86%, and 5 y: 67% vs 78%). Among older adults, in univariate Cox regressions, dialysis [hazards ratio (HR): 1.96, 95% CI: 1.38-2.77] and poor functional status [defined as Karnofsky Performance Score (KPS) <40] (HR: 1.82, 95% CI: 1.31-2.53) were each associated with mortality, remaining significant on multivariable Cox regressions. The effect of dialysis and KPS <40 at LT on post-LT survival (HR: 2.67, 95% CI: 1.77-4.01) was worse than the effects of either KPS <40 (HR: 1.52, 95% CI: 1.03-2.23) or dialysis alone (HR: 1.44, 95% CI: 0.62-3.36). Older recipients with KPS >40 without dialysis had comparable survival rates compared with younger recipients ( P = 0.30).

CONCLUSIONS

While older DDLT recipients had worse overall post-LT survival compared with younger recipients, favorable survival rates were observed among older adults who did not require dialysis and had poor functional status. Poor functional status and dialysis at LT may be useful to stratify older adults at higher risk for poor post-LT outcomes.

Frailty Changes After Liver Transplantation. Results From a Spanish Multicenter Prospective Cohort Study

Introduction

Until now, there has been limited evidence, primarily from US cohorts, focusing on frailty as a patient-oriented outcome after liver transplantation (LT). Our study aimed to explore the relationship between pre- and post-LT frailty in a multicenter European cohort of outpatients with cirrhosis undergoing LT.

Methods

We conducted a prospective analysis of data from 180 LT recipients recruited between 2018 and 2020 from 5 Spanish centers. Participants underwent objective and subjective frailty assessments using the Liver Frailty Index (LFI) and the Subjective Clinician Assessment (SCA) pretransplant and at 3- and/or 6-mo posttransplant.

Results

The median pretransplant LFI was 3.9, showing minimal change at 3 mo (3.8; P = 0.331) and improvement at 6-mo post-LT (3.6; P = 0.001). Conversely, the SCA significantly improved early post-LT: at 3 mo, poor SCA decreased from 11% to 1%, and good SCA increased from 54% to 89% (P < 0.001), remaining stable between 3- and 6-mo post-LT. Multivariable analysis revealed that each 0.1 increase in pretransplant LFI correlated with a reduced probability of being robust at 3-mo (odds ratio [OR] = 0.75; P < 0.001) and 6-mo post-LT (OR = 0.74; P < 0.001). There was poor concordance between SCA and LFI, with SCA underestimating frailty both pre- and post-LT (Kappa < 0.20).

Conclusion

In our European cohort, incomplete improvement of physical frailty was observed, with <20% achieving robust physical condition within 6-mo post-LT. The pretransplant LFI strongly predicted posttransplant frailty. As the SCA tends to overestimate physical function, we recommend using both subjective and objective tools for frailty assessment in LT candidates and recipients.

The impact of Karnofsky performance status on prognosis of patients with hepatocellular carcinoma in liver transplantation

BACKGROUND

Functional performance as measured by the Karnofsky Performance Status (KPS) scale has been linked to the outcomes of liver transplant patients; however, the effect of KPS on the outcomes of the hepatocellular carcinoma (HCC) liver transplant population has not been fully elucidated. We aimed to investigate the association between pre-transplant KPS score and long-term outcomes in HCC patients listed for liver transplantation.

METHODS

Adult HCC candidates listed on the Scientific Registry of Transplant Recipients (SRTR) database from January 1, 2011 to December 31, 2017 were grouped into group I (KPS 80-100%, n = 8,379), group II (KPS 50-70%, n = 8,091), and group III (KPS 10-40%, n = 1,256) based on percentage KPS score at listing. Survival was compared and multivariable analysis was performed to identify independent predictors.

RESULTS

Patients with low KPS score had a higher risk of removal from the waiting list. The 5-year intent-to-treat survival was 57.7% in group I, 53.2% in group II and 46.7% in group III (P < 0.001). The corresponding overall survival was 77.6%, 73.7% and 66.3% in three groups, respectively (P < 0.001). Multivariable analysis demonstrated that KPS was an independent predictor of intent-to-treat survival (P < 0.001, reference group I; HR 1.19 [95%CI 1.07-1.31] for group II, P = 0.001; HR 1.63 [95%CI 1.34-1.99] for group III, P < 0.001) and overall survival(P < 0.001, reference group I; HR 1.16 [95%CI 1.05-1.28] for group II, P = 0.004; HR 1.53 [95%CI 1.26-1.87] for group III, P < 0.001). The cumulative 5-year recurrence rates was higher in group III patients (7.4%), compared with 5.2% in group I and 5.5% in group II (P = 0.037). However, this was not significant in the competing regression analysis.

CONCLUSIONS

Low pre-transplant KPS score is associated with inferior long-term survival in liver transplant HCC patients, but is not significantly associated with post-transplant tumor recurrence.

Reduced length of intensive care unit stay and early mechanical ventilator weaning with enhanced recovery after surgery (ERAS) in free fibula flap surgery

This study aimed to evaluate the effects of the enhanced recovery after surgery (ERAS) program on postoperative recovery of patients who underwent free fibula flap surgery for mandibular reconstruction. This retrospective study included 188 patients who underwent free fibula flap surgery for complex mandibular and soft tissue defects between January 2011 and December 2022. We divided them into two groups: the ERAS group, consisting of 36 patients who were treated according to the ERAS program introduced from 2021 to 2022. Propensity score matching was used for the non-ERAS group, which comprised 36 cases selected from 152 patients between 2011 and 2020, based on age, sex, and smoking history. After propensity score matching, the ERAS and non-ERAS groups included 36 patients each. The primary outcome was the length of intensive care unit (ICU) stay; the secondary outcomes were flap complications, unplanned reoperation, 30-day readmission, postoperative ventilator use length, surgical site infections, incidence of delirium within ICU, lower-limb comorbidities, and morbidity parameters. There were no significant differences in the demographic characteristics of the patients. However, the ERAS group showed the lower length of intensive care unit stay (ERAS vs non-ERAS: 8.66 ± 3.90 days vs. 11.64 ± 5.42 days, P = 0.003) and post-operative ventilator use days (ERAS vs non-ERAS: 1.08 ± 0.28 days vs. 2.03 ± 1.05 days, P < 0.001). Other secondary outcomes were not significantly different between the two groups. Additionally, patients in the ERAS group had lower postoperative morbidity parameters, such as postoperative nausea, vomiting, urinary tract infections, and pulmonary complications (P = 0.042). The ERAS program could be beneficial and safe for patients undergoing free fibula flap surgery for mandibular reconstruction, thereby improving their recovery and not increasing flap complications and 30-day readmission.

Nutritional status and its correlation to prognosis of nasopharyngeal carcinoma patients in different ages in China: a multicenter cohort study

Nasopharyngeal carcinoma (NPC) patients usually presented malnutrition under chemoradiotherapy (CRT)/radiotherapy (RT). Few studies stratified by age to investigate the association of nutritional status with overall survival (OS) in NPC patients. This study aimed to explore the nutritional parameters related prognosis of NPC patients in different age. The total 1365 NPC patients were classified into young (18~45), middle-aged (46~60), and old groups (> 60). PG-SGA scores, NRS-2002 scores, Karnofsky performance status scores, anthropometric, and blood indicators (albumin, prealbumin, transferrin, C-reactive protein, hemoglobin, and total lymphocyte) were assessed. Cox regression analysis was performed to evaluate the association between risk factors of nutritional status and the overall survival in different age group of NPC patients. Kaplan-Meier (KM) survival analysis was used to estimate the effect of nutritional indexes on prognosis. The abnormal rate of albumin, prealbumin, hemoglobin, hand grip strength, and calf circumference increased with age. The malnutrition occurred in all age group and low calf circumference (HR, 4.427, 1.167-16.791) was an independent death risk in young adults. Distant metastasis (HR, 4.754, 2.737-8.260), low albumin (HR, 3.530, 1.708-7.296), hand grip strength (HR, 1.901, 1.160-3.115), and the nutritional intervention requirement (NRS-2002 ≥ 3) (HR, 2.802, 1.211-6.483) was significantly correlated with poor OS in NPC patients with middled age adults. Distant metastasis (HR, 2.546, 1.497-4.330), low albumin (HR, 1.824, 0.949-3.507), low hemoglobin (HR, 1.757, 1.015-3.044), low hand grip strength (HR, 1.771, 1.112-2.818), and low calf circumference (HR, 1.951, 1.074-3.545) were associated with increased risk of death in the elderly. KM analysis indicated that over 60 years, distant metastasis, low albumin, low hand grip strength, low calf circumference, and malnutritional risk (NRS-2002 ≥ 3) were correlated to prognosis of NPC patients. Low calf circumference could be a prognosis not only in elderly but also in young adults of NPC patients, whereas low albumin and distant metastasis were the prognostic factors in middle-aged and elderly patients. Patients aged over 60 years exhibited poorer OS compared with young and middle-aged adults.

Pretransplant Functional Status Predicts Postoperative Morbidity and Mortality after Liver Transplantation in Patients with Cirrhosis

Background/Aims

This study aimed to investigate whether pretransplant frailty can predict postoperative morbidity and mortality after liver transplantation (LT) in patients with cirrhosis.

Methods

We retrospectively reviewed 242 patients who underwent LT between 2018 and 2020 at a tertiary hospital in Korea.

Results

Among them, 189 patients (78.1%) received LT from a living donor. Physical frailty at baseline was assessed by the Short Physical Performance Battery (SPPB), by which patients were categorized into two groups: frail (SPPB <10) and non-frail (SPPB ≥10). Among the whole cohort (age, 55.0±9.2 years; male, 165 [68.2%]), 182 patients were classified as non-frail and 60 patients were classified as frail. Posttransplant survival was shorter in the frail group than the non-frail group (9.3 months vs 11.6 months). Postoperative intensive care unit stay was longer in the frail group than in the non-frail group (median, 6 days vs 4 days), and the 30-day complication rate was higher in the frail group than in the non-frail group (78.3% vs 59.3%). Frailty was an independent risk factor for posttransplant mortality (adjusted hazard ratio, 2.38; 95% confidence interval, 1.02 to 5.57). In subgroup analysis, frail patients showed lower posttransplant survival regardless of history of hepatocellular carcinoma and donor type.

Conclusions

Assessment of pretransplant frailty, as measured by SPPB, provides important prognostic information for clinical outcomes in cirrhotic patients undergoing LT.

Early growth response 1 promoted the invasion of glioblastoma multiforme by elevating HMGB1

BACKGROUND

Glioblastoma multiforme (GBM) is the most common and deadly glioma subtype. Early growth response 1 (EGR1) participates in the progression of several cancer types, but the expression and function of EGR1 in GBM was rarely investigated.

METHODS

The expressions of EGR1 in GBM were detected with qRT-PCR and immunohistochemistry in 12 pairs of fresh GBM tissues and 116 paraffin-embedded specimens. The patients were divided into high and low EGR1 groups according to the IHC score of EGR1, and the prognostic significances of different groups were evaluated with univariate and multivariate analyses. With in-vitro experiments, we assessed the role of EGR1 in the proliferation and invasion of GBM cells.

RESULTS

In our study, EGR1 was up-regulated in GBM tissues compared with tumor-adjacent normal tissues. High expression of EGR1 or HMGB1 were unfavorable prognostic biomarkers of GBM. Coexpression of EGR1 and HMGB1 could predict the prognosis of GBM more sensitively. EGR1 facilitated the proliferation and invasion of GBM cells. Moreover, EGR1 promoted the invasion, instead of proliferation, of GBM cells by elevating the expression of HMGB1.

CONCLUSIONS

ERG1 was a prognostic biomarker of GBM, and ERG1 and HMGB1 synergistically could predict the GBM prognosis more precisely. ERG1 could promote GBM cell invasion by inducing HMGB1 expression.

Proteogenomics of clear cell renal cell carcinoma response to tyrosine kinase inhibitor

The tyrosine kinase inhibitor (TKI) Sunitinib is one the therapies approved for advanced renal cell carcinoma. Here, we undertake proteogenomic profiling of 115 tumors from patients with clear cell renal cell carcinoma (ccRCC) undergoing Sunitinib treatment and reveal the molecular basis of differential clinical outcomes with TKI therapy. We find that chromosome 7q gain-induced mTOR signaling activation is associated with poor therapeutic outcomes with Sunitinib treatment, whereas the aristolochic acid signature and VHL mutation synergistically caused enhanced glycolysis is correlated with better prognosis. The proteomic and phosphoproteomic analysis further highlights the responsibility of mTOR signaling for non-response to Sunitinib. Immune landscape characterization reveals diverse tumor microenvironment subsets in ccRCC. Finally, we construct a multi-omics classifier that can detect responder and non-responder patients (receiver operating characteristic-area under the curve, 0.98). Our study highlights associations between ccRCC molecular characteristics and the response to TKI, which can facilitate future improvement of therapeutic responses.

Physical Performance Decline During the Early Posttransplantation Period Affects Survival After Living Donor Liver Transplantation

BACKGROUND

Patient physical performance has been emphasized in liver transplant recipients; however, evidence for living donor liver transplantation (LDLT) patients is lacking. This study investigated the impact of physical performance decline during the early posttransplantation period on survival and risk factors for this decline in LDLT recipients.

METHODS

From national registry data, 2703 LDLT patients were divided into 2 groups based on the change in their Karnofsky performance status (KPS) between 1 and 6 mo posttransplantation: declined KPS (n = 188) and control (n = 2515). Multivariable analyses were conducted to control for confounders, including posttransplantation complications.

RESULTS

Estimated 5-y patient survival rates were 91.6% in the declined KPS group and 96.3% in the control group, favoring the latter ( P = 0.003). The survival hazard of KPS decline was significant in a baseline covariates-adjusted Cox model (hazard ratio [HR], 2.60; 95% confidence interval [CI], 1.37-4.95) and an adjusted model accounting for posttransplantation complications (HR, 3.38; 95% CI, 1.70-6.72). In subgroup analyses, KPS decline independently reduced survival in patients without complications (HR, 3.95; 95% CI, 1.67-9.34), and the trend was similar in patients with complications, although significance was marginal (HR, 3.02; 95% CI, 0.98-9.27). We found that only posttransplantation complications, such as rejection, infection, bile duct complication, and vascular complication, were significant risk factors for KPS decline after LDLT.

CONCLUSIONS

Physical performance decline during the early posttransplantation period independently reduced survival rates, and posttransplantation complications were the only significant risk factors for physical performance decline in LDLT recipients.

Liver transplantation in the patient with physical frailty

Frailty is a decline in functional reserve across multiple physiological systems. A key component of frailty is sarcopenia, which denotes a loss of skeletal muscle mass and impaired contractile function that ultimately result in physical frailty. Physical frailty/sarcopenia are frequent and contribute to adverse clinical outcomes before and after liver transplantation. Frailty indices, including the liver frailty index, focus on contractile dysfunction (physical frailty), while cross-sectional image analysis of muscle area is the most accepted and reproducible measure to define sarcopenia. Thus, physical frailty and sarcopenia are interrelated. The prevalence of physical frailty/sarcopenia is high in liver transplant candidates and these conditions have been shown to adversely impact clinical outcomes including mortality, hospitalisations, infections, and cost of care both before and after transplantation. Data on the prevalence of frailty/sarcopenia and their sex- and age-dependent impact on outcomes are not consistent in patients on the liver transplant waitlist. Physical frailty and sarcopenic obesity are frequent in the obese patient with cirrhosis, and adversely affect outcomes after liver transplantation. Nutritional interventions and physical activity remain the mainstay of management before and after transplantation, despite limited data from large scale trials. In addition to physical frailty, there is recognition that a global evaluation including a multidisciplinary approach to other components of frailty (e.g., cognition, emotional, psychosocial) also need to be addressed in patients on the transplant waitlist. Recent advances in our understanding of the underlying mechanisms of sarcopenia and contractile dysfunction have helped identify novel therapeutic targets.

Selecting DCD Recipients Using Predictive Indices

Donation after circulatory death (DCD) allografts might represent one of the largest untapped sources of liver allografts. Our aim was to identify independent recipient risk factors that predict mortality in DCD allograft recipients to preselect optimal candidates for successful transplantation. Furthermore, we compared the application of our newly constructed DCD Recipient Selector Index (RSI) score to previously developed models to determine superiority in predicting recipient survival.

Methods

Using the Organ Procurement and Transplantation Network database, we performed univariate and multivariate retrospective analyses on 4228 DCD liver allograft recipients.

Results

We identified 8 significant factors and incorporated them into the weighted RSI to predict 3-mo survival following DCD liver transplantation with a C-statistic of 0.6971. The most significant recipient risk factors were recipient serum sodium levels >150 mEq/L at transplant, recipient albumin <2.0 g/dL at transplant, and a history of portal vein thrombosis. Because Model for End-Stage Liver Disease (MELD) score components were included as individual predictors, the DCD RSI predicts survival independently of MELD. Upon comparison with 3 previous recipient risk scores-Balance of Risk, Renal Risk Index, Patient-Survival Outcomes Following Liver Transplantation-the DCD RSI was determined to be superior at selecting optimal candidates pre-DCD transplantation, yielding a C-statistic of 0.6971.

Conclusions

After verifying the performance of predictive indices for selection of DCD recipients, the DCD RSI is best used to preselect patients for optimized outcomes after DCD transplantation. This can increase utilization of DCD donors by improving outcomes.

Albumin–Globulin Score Combined with Skeletal Muscle Index as a Novel Prognostic Marker for Hepatocellular Carcinoma Patients Undergoing Liver Transplantation

Background: Sarcopenia was recently identified as a poor prognostic factor in patients with malignant tumors. The present study investigated the effect of the preoperative albumin–globulin score (AGS), skeletal muscle index (SMI), and combination of AGS and SMI (CAS) on short- and long-term survival outcomes following deceased donor liver transplantation (DDLT) for hepatocellular carcinoma (HCC) and aimed to identify prognostic factors. Methods: A total of 221 consecutive patients who underwent DDLT for HCC were enrolled in this retrospective study between January 2015 and December 2019. The skeletal muscle cross-sectional area was measured by CT (computed tomography). Clinical cutoffs of albumin (ALB), globulin (GLB), and sarcopenia were defined by receiver operating curve (ROC). The effects of the AGS, SMI, and CAS grade on the preoperative characteristics and long-term outcomes of the included patients were analyzed. Results: Patients who had low AGS and high SMI were associated with better overall survival (OS) and recurrence-free survival (RFS), shorter intensive care unit (ICU) stay, and fewer postoperative complications (grade ≥ 3, Clavien–Dindo classification). Stratified by CAS grade, 46 (20.8%) patients in grade 1 were associated with the best postoperative prognosis, whereas 79 (35.7%) patients in grade 3 were linked to the worst OS and RFS. The CAS grade showed promising accuracy in predicting the OS and RFS of HCC patients [areas under the curve (AUCs) were 0.710 and 0.700, respectively]. Male recipient, Child–Pugh C, model for end-stage liver disease (MELD) score > 20, and elevated CAS grade were identified as independent risk factors for OS and RFS of HCC patients after DDLT. Conclusion: CAS grade, a novel prognostic index combining preoperative AGS and SMI, was closely related to postoperative short-term and long-term outcomes for HCC patients who underwent DDLT. Graft allocation and clinical decision making may be referred to CAS grade evaluation.

Lymphopenia at the time of transplant is associated with short-term mortality after deceased donor liver transplantation

Absolute lymphocyte count (ALC) is considered a surrogate marker for nutritional status and immunocompetence. We investigated the association between ALC and post-liver transplant outcomes in patients who received a deceased donor liver transplant (DDLT). Patients were categorized by ALC at liver transplant: low (<500/μL), mid (500-1000/μL), and high ALC (>1000/μL). Our main analysis used retrospective data (2013-2018) for DDLT recipients from Henry Ford Hospital (United States); the results were further validated using data from the Toronto General Hospital (Canada). Among 449 DDLT recipients, the low ALC group demonstrated higher 180-day mortality than mid and high ALC groups (83.1% vs 95.8% and 97.4%, respectively; low vs mid: P = .001; low vs high: P < .001). A larger proportion of patients with low ALC died of sepsis compared with the combined mid/high groups (9.1% vs 0.8%; P < .001). In multivariable analysis, pretransplant ALC was associated with 180-day mortality (hazard ratio, 0.20; P = .004). Patients with low ALC had higher rates of bacteremia (22.7% vs 8.1%; P < .001) and cytomegaloviremia (15.2% vs 6.8%; P = .03) than patients with mid/high ALC. Low ALC pretransplant through postoperative day 30 was associated with 180-day mortality among patients who received rabbit antithymocyte globulin induction (P = .001). Pretransplant lymphopenia is associated with short-term mortality and a higher incidence of posttransplant infections in DDLT patients.

Sarcopenia and Frailty in Cirrhosis

Sarcopenia and frailty are frequent in cirrhosis, and both contribute to increased morbidity and mortality. The complex pathogenesis of sarcopenia in cirrhosis is mainly determined by hyperammonemia and malnutrition. Sarcopenia/frailty screening and reevaluation should be undertaken in all cirrhotic patients. Frailty tests are useful in the ambulatory setting, whereas the computed tomography scan is the diagnostic gold standard for sarcopenia. To manage sarcopenia/frailty, a multidisciplinary team should develop a personalized comprehensive care plan that includes patient education, protein/calorie intake goals, late evening meals, exercise programs, and micronutrient replenishment. In selected patients, branched-chain amino acid and testosterone supplements may also be beneficial.

Efficacy and safety of total lymphoid irradiation in different chronic lung allograft dysfunction phenotypes

Total lymphoid irradiation (TLI) is an alternative treatment for chronic lung allograft dysfunction (CLAD). However, data regarding its efficacy and tolerance are scarce. This study included patients with CLAD treated with TLI at our center between 2011 and 2018. Clinical characteristics before and after TLI and related complications were analyzed. Forty patients with CLAD (twenty-nine bronchiolitis obliterans syndrome [BOS], nine restrictive allograft syndrome [RAS], and two mixed) were included. Significant attenuation of the forced expiratory volume in 1-sec (FEV₁ ) decline slope was observed in all phenotypes, in both the BOS and RAS. The median FEV₁ 12, 6, and 3 months pre-TLI were as follows: 1980 (IQR 1720-2560), 1665 (IQR 1300-2340) and 1300 (IQR 1040-1740) ml (p < .001), while the median FEV₁ at 3, 6, and 12 months post-TLI was 1110 (IQR 810-1440), 1130 (IQR 860-1470), and 1115 (IQR 865-1490) ml (p = .769). No dropouts due to radiation toxicity were observed. The mean survival according to the Karnofsky Performance Status Scale (KPS) >70 or ≤70 at baseline was 1837 (IQR 259-2522) versus 298 (IQR 128-554) days (p < .0001), respectively. In conclusion, TLI may stop FEV₁ decline in both BOS and RAS. Moreover, a good KPS score may be an important prognostic factor.

Association of Frailty With Health-Related Quality of Life in Liver Transplant Recipients

Importance

Frailty has been recognized as a risk factor for mortality after liver transplant (LT) but little is known of its association with functional status and health-related quality of life (HRQL), termed global functional health, in LT recipients.

Objective

To evaluate the association between pre-LT and post-LT frailty with post-LT global functional health.

Design, Setting, and Participants

This prospective cohort study was conducted at 8 US LT centers and included adults who underwent LT from October 2016 to February 2020.

Exposures

Frail was defined by a pre-LT Liver Frailty Index (LFI) score of 4.5 or greater.

Main Outcomes and Measures

Global functional health at 1 year after LT, assessed using surveys (Short Form-36 [SF-36; summarized by physical component scores (PFC) and mental component summary scores (MCS)], Instrumental Activities of Daily Living scale) and performance-based tests (LFI, Fried Frailty Phenotype, and Short Physical Performance Battery).

Results

Of 358 LT recipients (median [IQR] age, 60 [53-65] years; 115 women [32%]; 25 [7%] Asian/Pacific Islander, 21 [6%] Black, 54 [15%] Hispanic White, and 243 [68%] non-Hispanic White individuals), 68 (19%) had frailty pre-LT. At 1 year post-LT, the median (IQR) PCS was lower in recipients who had frailty vs those without frailty pre-LT (42 [31-53] vs 50 [38-56]; P = .002), but the median MCS was similar. In multivariable regression, pre-LT frailty was associated with a -5.3-unit lower post-LT PCS (P < .001), but not MCS. The proportion who had difficulty with 1 or more Instrumental Activities of Daily Living (21% vs 10%) or who were unemployed/receiving disability (38% vs 29%) was higher in recipients with vs without frailty. In a subgroup of 210 recipients with LFI assessments 1 year post-LT, 13% had frailty at 1 year post-LT. Recipients who had frailty post-LT reported lower adjusted SF-36-PCS scores (coefficient, -11.4; P < .001) but not SF-36-MCS scores. Recipients of LT who had frailty vs those without frailty 1 year post-LT also had worse median (IQR) Fried Frailty Phenotype scores (1 [1-2] vs 1 [0-1]) and higher rates of functional impairment by a Short Physical Performance Battery of 9 or less (42% vs 20%; P = .01).

Conclusions and Relevance

In this cohort study, pre-LT frailty was associated with worse global functional health 1 year after LT. The presence of frailty after LT was also associated with worse HRQL in physical, but not mental, subdomains. These data suggest that interventions and therapeutics that target frailty that are administered before and/or early post-LT may help to improve the health and well-being of LT recipients.

Sarcopenia Predicts Prognosis of Patients Undergoing Liver Resection for Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Recently, several studies have investigated the impact of preoperative sarcopenia on the prognosis of patients with hepatocellular carcinoma (HCC) after liver resection, but their conclusions are controversial. Therefore, we performed a meta-analysis to evaluate the prognostic role of sarcopenia in HCC patients undergoing liver resection. PubMed, SinoMed, Embase, Cochrane Library, Medline, and Web of Science databases were systematically searched for all published literature on the prognostic value of preoperative sarcopenia in HCC patients undergoing liver resection. Pooled hazard ratios (HR), odds ratios (OR) and weighted mean differences (WMD) of the 95% confidence intervals (95% CI) were estimated using a fixed-effects or random-effects model. A total of 12 articles with 1,774 patients were included. The results of meta-analysis showed that sarcopenia would increase postoperative complications (OR = 1.30, 95%CI 1.03 ∼ 1.65, P = 0.03), prolong hospital stay (SMD = 0.22, 95%CI 0.05 ∼ 0.39, P = 0.01), and also be associated with shorter overall survival (OS) (HR = 1.69, 95%CI 1.09 ∼ 2.62, P = 0.02) and worse disease free survival (DFS) (HR = 1.54, 95%CI 1.23 ∼ 1.93, P < 0.01). Sarcopenia has an adverse effect on the prognosis of HCC patients undergoing liver resection.

Orthopedic therapeutic surgery for bone metastasis of liver cancer: Clinical efficacy and prognostic factors

Objectives

In this study, the objectives were to investigate the clinical efficacy of orthopedic therapeutic surgery (OTS) in patients with bone metastasis of liver cancer and explore the prognostic factors.

Methods

The electronic medical records of patients with bone metastasis of liver cancer in the Third Affiliated Hospital of Naval Medical University from September 2016 to August 2021 were retrospectively collected. A total of 53 patients were included. Patients were assigned to the OTS (n = 35) or the control group (n = 18) based on receiving orthopedic therapeutic surgery or conservative treatment. The pre/posttreatment Karnofsky Performance Status scale (KPS) and numeric rating scale (NRS) scores were compared. Univariate and multivariate Cox regression analyses were used to explore the prognostic factors affecting survival after bone metastasis. Logistic regression analyses were adopted to discover potential factors that contributed to greater KPS score improvement.

Results

The axial bone accounted for 69.8% of all bone metastases. The proportion of multiple bone metastases was 52.8%. After surgery, the median KPS score of the OTS group increased from 60 to 80 (p &lt; 0.001), and the median increase in the OTS group was higher than that of the control group (p = 0.033). The median NRS score of the OTS group declined from 6 to 2 after surgery (p &lt; 0.001), and the median decline in the OTS group was higher (p = 0.001). The median survival was 10 months in the OTS group vs. 6 months in the control group (p &lt; 0.001). Higher pretreatment KPS scores, undergoing liver primary lesion surgery, and undergoing orthopedic therapeutic surgery were protective factors of survival. Undergoing orthopedic therapeutic surgery greatly improved the KPS score.

Conclusions

Orthopedic therapeutic surgery for bone metastasis of liver cancer provides benefits to the quality of life. Patients who have their primary liver lesions removed, undergo orthopedic therapeutic surgery, and have a better physical condition before treatment tend to have longer survival.

Predictors of surgical site infection in glioblastoma patients undergoing craniotomy for tumor resection

OBJECTIVE

Surgical site infections (SSIs) burden patients and healthcare systems, often requiring additional intervention. The objective of this study was to identify the relationship between preoperative predictors inclusive of scalp incision type and postoperative SSI following glioblastoma resection.

METHODS

The authors retrospectively reviewed cases of glioblastoma resection performed at their institution from December 2006 to December 2019 and noted preoperative demographic and clinical presentations, excluding patients missing these data. Preoperative nutritional indices were available for a subset of cases. Scalp incisions were categorized as linear/curvilinear, reverse question mark, trapdoor, or frontotemporal. Patients were dichotomized by SSI incidence. Multivariable logistic regression was used to determine predictors of SSI.

RESULTS

A total of 911 cases of glioblastoma resection were identified, 30 (3.3%) of which demonstrated postoperative SSI. There were no significant differences in preoperative malnutrition or number of surgeries between SSI and non-SSI cases. The SSI cases had a significantly lower preoperative Karnofsky Performance Status (KPS) than the non-SSI cases (63.0 vs 75.1, p < 0.0001), were more likely to have prior radiation history (43.3% vs 26.4%, p = 0.042), and were more likely to have received steroids both preoperatively and postoperatively (83.3% vs 54.5%, p = 0.002). Linear/curvilinear incisions were more common in non-SSI than in SSI cases (56.9% vs 30.0%, p = 0.004). Trapdoor scalp incisions were more frequent in SSI than non-SSI cases (43.3% vs 24.2%, p = 0.012). On multivariable analysis, a lower preoperative KPS (OR 1.04, 95% CI 1.02–1.06), a trapdoor scalp incision (OR 3.34, 95% CI 1.37–8.49), and combined preoperative and postoperative steroid administration (OR 3.52, 95% CI 1.41–10.7) were independently associated with an elevated risk of postoperative SSI.

CONCLUSIONS

The study findings indicated that SSI risk following craniotomy for glioblastoma resection may be elevated in patients with a low preoperative KPS, a trapdoor scalp incision during surgery, and steroid treatment both preoperatively and postoperatively. These data may help guide future operative decision-making for these patients.

Current Medical Treatment for Alcohol-Associated Liver Disease

Alcohol-associated liver disease is one of the main causes of chronic liver disease. It comprises a clinical-histologic spectrum of presentations, from steatosis, steatohepatitis, to different degrees of fibrosis, including cirrhosis and severe necroinflammatory disease, called alcohol-associated hepatitis. In this focused update, we aim to present specific therapeutic interventions and strategies for the management of alcohol-associated liver disease. Current evidence for management in all spectra of manifestations is derived from general chronic liver disease recommendations, but with a higher emphasis on abstinence and nutritional support. Abstinence should comprise the treatment of alcohol use disorder as well as withdrawal syndrome. Nutritional assessment should also consider the presence of sarcopenia and its clinical manifestation, frailty. The degree of compensation of the disease should be evaluated, and complications, actively sought. The most severe acute form of this disease is alcohol-associated hepatitis, which has high mortality and morbidity. Current treatment is based on corticosteroids that act by reducing immune activation and blocking cytotoxicity and inflammation pathways. Other aspects of treatment include preventing and treating hepatorenal syndrome as well as preventing infections although there is no clear evidence as to the benefit of probiotics and antibiotics in prophylaxis. Novel therapies for alcohol-associated hepatitis include metadoxine, interleukin-22 analogs, and interleukin-1-beta antagonists. Finally, granulocyte colony-stimulating factor, microbiota transplantation, and gut-liver axis modulation have shown promising results. We also discuss palliative care in advanced alcohol-associated liver disease.

Non-Renal Risk Factors for Chronic Kidney Disease in Liver Recipients with Functionally Intact Kidneys at 1 Month

Chronic kidney disease (CKD) is a critical complication of liver transplants, of which non-renal risk factors are not fully understood yet. This study aimed to reveal pre- and post-transplant risk factors for CKD (<60 mL/min/1.73 m2), examining liver recipients with functionally intact kidneys one month after grafting using nationwide cohort data. Baseline risk factors were analyzed with multivariable Cox regression analyses and post-transplant risk factors were investigated with the time-dependent Cox model and matched analyses of time-conditional propensity scores. Of the 2274 recipients with a one-month eGFR ≥ 60 mL/min/1.73 m2, 494 (22.3%) developed CKD during a mean follow-up of 36.6 ± 14.4 months. Age, female sex, lower body mass index, pre-transplant diabetes mellitus, and lower performance status emerged as baseline risk factors for CKD. Time-dependent Cox analyses revealed that recurrent hepatocellular carcinoma (HR = 1.93, 95% CI 1.06−3.53) and infection (HR = 1.44, 95% CI 1.12−1.60) were significant post-transplant risk factors for CKD. Patients who experienced one of those factors showed a significantly higher risk of subsequent CKD compared with the matched controls who lacked these features (p = 0.013 for recurrent hepatocellular carcinoma, and p = 0.003 for infection, respectively). This study clarifies pre- and post-transplant non-renal risk factors, which lead to renal impairment after LT independently from patients’ renal functional reserve.

Survival After Liver Transplantation: An International Comparison Between the United States and the United Kingdom in the Years 2008-2016

BACKGROUND

Compared with the United States, risk-adjusted mortality in the United Kingdom has historically been worse in the first 90 d following liver transplantation (LT) and better thereafter. In the last decade, there has been considerable change in the practice of LT internationally, but no contemporary large-scale international comparison of posttransplant outcomes has been conducted. This study aimed to determine disease-specific short- and long-term mortality of LT recipients in the United States and the United Kingdom.

METHODS

This retrospective international multicenter cohort study analyzed adult (≥18 y) first-time LT recipients between January 2, 2008, and December 31, 2016, using the Organ Procurement and Transplantation Network/United Network for Organ Sharing and the UK Transplant Registry databases. Time-dependent Cox regression estimated hazard ratios (HRs) comparing disease-specific risk-adjusted mortality in the first 90 d post-LT, between 90 d and 1 y, and between 1 and 5 y.

RESULTS

Forty-two thousand eight hundred seventy-four US and 4950 UK LT recipients were included. The main LT indications in the United States and the United Kingdom were hepatocellular carcinoma (25.4% and 24.9%, respectively) and alcohol-related liver disease (20.3% and 27.1%, respectively). There were no differences in mortality during the first 90 d post-LT (reference: United States; HR, 0.96; 95% confidence interval [CI], 0.82-1.12). However, between 90 d and 1 y (HR, 0.71; 95% CI, 0.59-0.85) and 1 and 5 y (HR, 0.71; 95% CI, 0.63-0.81]) the United Kingdom had lower mortality. The mortality differences between 1 and 5 y were most marked in hepatocellular carcinoma (HR, 0.71; 95% CI, 0.58-0.88) and alcohol-related liver disease patients (HR, 0.64; 95% CI, 0.45-0.89).

CONCLUSIONS

Risk-adjusted mortality in the United States and the United Kingdom was similar in the first 90 d post-LT but better in the United Kingdom thereafter. International comparisons of LT may highlight differences in healthcare delivery and help benchmarking by identifying modifiable factors that can facilitate improved global outcomes in LT.

Functional status of heart transplant recipients predicts survival

INTRODUCTION

Recipient functional status prior to transplantation can significantly impact post-transplant survival.

METHODS

The United Network for Organ Sharing database was queried for adult heart transplants including data on functional capacity and from February 1, 2005 to March 1, 2021; there were 32 875 cases included. The four functional categories studied were based on adult daily activities of living and were separated into total assistance required, some assistance required, no assistance required, and near death. Survival outcomes were compared for recipient's pretransplant level of functional status versus those with near death status. These were compared using adjusted logistic regression (odds of death at 30 days and 1 year) and conditional Cox models (overall survival and time until post-transplant rejection). All models were adjusted for donor age, sex, ethnicity, ischemic time, as well as recipient age, sex, ethnicity, length of stay, UNOS region, ventricular assist device, creatinine, days on the waiting list, and status at transplant.

RESULTS

There were 12 953 recipients classified as "near death" or "severely disabled"; 7711 "required total assistance in daily living", 7,328 "needed some", and 4883 "needed none". In adjusted models, the probabilities of death for the lowest functioning groups within 30 days and 1 year were 5% and 10%, respectively. Those "requiring total assistance" had analogous probabilities of 3% (OR = 0.58; p < 0.001) and 9% (OR = 0.81; p < 0.001). Those "requiring some assistance" had probabilities of 3% (OR = 0.56; p < 0.001) and 9% (OR = 0.74; p < 0.001). Lastly, those "requiring no assistance" had probabilities of death of 2% (OR = 0.35; p < 0.001) and 7% (OR = 0.63; p < 0.001).

CONCLUSION

Recipient functional status assessed pre-transplant and recorded in the UNOS database is a strong predictor of post-transplant survival.

A decline in functional status while awaiting liver transplantation is predictive of increased post-transplantation mortality

BACKGROUND

Functional status (FS) is dynamic and changes over time. We examined how changes in FS while awaiting liver transplantation influence post-transplant outcomes.

METHODS

Data on adult liver transplants performed in the United States during the MELD era were obtained through September 2020. Patient and graft survival were compared between groups with no change or improved FS, and those with worsening FS.

RESULTS

Of the 90,210 transplant recipients included in the analysis, 39,193 (43%) had worsening FS, which was associated with longer waiting-list time (187 vs. 329 days, p < 0.001) and worse patient survival after liver transplant (1858 vs. 1727 days, p < 0.001). A consistent and dose-dependent relationship was observed for each 10-point decrease in Karnofsky Performance Score and post-transplant survival. Multivariable regression analysis confirmed that a decline in FS was associated with worse patient survival (HR 1.15, p < 0.001). Similar findings were observed for graft survival.

CONCLUSION

A decline in FS on the waiting-list is associated with significantly greater post-liver transplant mortality in recipients. These results should be taken into consideration when allocating organs and determining transplant candidacy. Strategies to optimize FS prior to transplantation should be prioritized as even subtle decreases in FS are associated with inferior post-transplantation outcomes.

Bevacizumab Combined with Intensity-Modulated Radiation Therapy on Cognitive and Coagulation Function in Postoperative Glioma Patients

To examine the influences of bevacizumab combined with intensity-modulated radiation therapy (IMRT) on postoperative brain glioma, particularly its impact on coagulation function and cognitive function, the complete clinical data of 156 patients undergoing glioma surgery in the neurosurgery department of our hospital between March 2015 and October 2018 were retrospectively analyzed. All patients underwent glioma surgery and were then assigned to the observation group (Obs group, n = 79, received bevacizumab combined with IMRT) or the control group (Con group, n = 77, received IMRT without bevacizumab) for analysis during postoperative treatment. The patients' short-term efficacy was evaluated, and their serum markers and coagulation function were compared, as well as the cognitive function, the occurrence of adverse reactions during treatment, the Karnofsky performance status (KPS) score, and quality of life after treatment. Patients' survival was followed up within 2 years after surgery. The Obs group showed a notably higher clinical remission rate and clinical control rate (DCR) than the Con group after treatment. The Obs group showed notably lower levels of interleukin-2 (IL-2), vascular endothelial growth factor (VEGF), IL-6, and epidermal growth factor (EGF), experienced notably shorter prothrombin time (PT) and activated partial thromboplastin time (APTT), and showed higher fibrinogen (FIB) and D-dimer (D-D) levels than Con group. The Obs group showed notably better cognitive function, KPS score, and quality of life than the Con group, but no notable difference was observed between them in the incidence of adverse reactions (P > 0.0500). The survival rates in the Obs group were higher than in the Con group. For patients with glioma, postoperative bevacizumab combined with IMRT delivers substantially higher clinical efficacy by lowering serum marker levels and improving cognitive function without significantly affecting coagulation function.

Impact of pretransplant frailty and sarcopenia on the post-transplant prognosis of patients with liver cirrhosis: a systematic review

INTRODUCTION

Frailty and sarcopenia associate with increased mortality in patients with liver cirrhosis on the transplant waitlist. We conducted a systematic review on the impact of pretransplant frailty and sarcopenia on post-transplant outcomes in adult patients with liver cirrhosis.

METHODS

We performed a search in Medline, Embase and Cochrane Central. Of the 12276 references initially recovered, 34 were included.

RESULTS

Frailty and sarcopenia presented a negative impact on post-transplant outcomes and seemed to associate with an overall two-fold reduction in early and 50% reduction in late survival, for severe conditions, according to the largest cohorts. These patients required longer ICU and hospitalization time, had higher rates of sepsis and respiratory complications and lower graft-survival. The reversibility of frailty depended on the severity of functional impairment and on the co-morbidities contributing to frailty. Reversibility of sarcopenia occurred in only a minority of patients, in unbiased studies.

CONCLUSION

Frailty and sarcopenia are double-edged swords: patients with frailty/sarcopenia should be prioritized for liver transplantation due to increased mortality on the waitlist; however, severe frailty/sarcopenia may justify delisting because it associates with dismal prognosis post-liver transplantation. Patients presenting mild to moderate frailty/sarcopenia, should be submitted to liver transplantation before those conditions worsen to a level that significantly impacts post-liver transplantation outcomes.

The Impact of Performance Status on Length of Hospital Stay and Clinical Complications Following Liver Transplantation

BACKGROUND

Impaired pretransplant performance status (PS) is associated with chronic liver disease (CLD). We studied its impact on hospital length of stay (LOS), complications, and readmissions in the first year after liver transplantation.

METHODS

The Standard National Liver Transplant Registry was linked to a hospital administrative dataset, and all first-time liver transplant recipients with CLD aged ≥18 years in England were identified. A modified 3-level Eastern Cooperative Oncology Group score was used to assess PS. Linear- and logistic-fixed effect regression models were used to estimate the effect of specific posttransplant complications and readmissions in the first year after transplantation.

RESULTS

Six thousand nine hundred sixty-eight recipients were included. Impaired PS was associated with an increased LOS in the initial posttransplant period (comparing ECOG 1-3, adjusted difference 7.2 d; 95% confidence [CI], 4.8-9.6; P < 0.001) and in time spent on the ITU (adjusted difference 1.2 d; 95% CI, 0.4-2.0; P < 0.001). There was no significant association between ECOG status and total LOS of later admissions (adjusted difference, 2.5 d; 95% CI, -0.4-5.5; P = 0.23). Those with a poorer ECOG status had an increased incidence of renal failure (odds ratio, 1.5; 95% CI, 1.1-2.0; P = 0.004) and infection (odds ratio, 1.2; 95% CI, 1.1-1.4; P = 0.02) but not an increased incidence of readmission (odds ratio, 1.2; 95% CI, 0.9-1.5; P = 0.13).

CONCLUSIONS

In liver transplant recipients with CLD, impaired pretransplant PS is associated with prolonged LOS in the immediate posttransplant period but not with LOS of later admissions in the first year after transplantation. Impaired PS increased the risk of renal failure and infection.

Physiologic Reserve Assessment and Application in Clinical and Research Settings in Liver Transplantation

Physiologic reserve is an important prognostic indicator. Because of its complexity, no single test can measure an individual's physiologic reserve. Frailty is the phenotypic expression of decreased reserve and portends poor prognosis. Both subjective and objective tools have been used to measure one or more components of physiologic reserve. Most of these tools appear to predict pretransplant mortality, but only some predict posttransplant survival. Incorporation of these measures of physiologic reserve in the clinical and research settings including prediction models are reviewed, and the applicability to patient-related outcomes are discussed. Commonly used tools, in patients with cirrhosis, that have been associated with clinical outcomes were reviewed. The strength of subjective tools lies in low-cost, wide availability, and quick assessments at the bedside. A disadvantage of these tools is the manipulative capacity, restricting their value in allocation processes. The strength of objective tests lies in objective measurements and the ability to measure change. The disadvantages include complexity, increased cost, and limited accessibility. Heterogeneity in the definitions and tools used has prevented further advancement or a clear role in transplant assessment. Consistent use of objective tools, including the 6-minute walk test, gait speed, Liver Frailty Index, or Short Physical Performance Battery, are recommended in clinical and research settings.

Sarcopenia and frailty in decompensated cirrhosis

In patients with decompensated cirrhosis, sarcopenia and frailty are prevalent. Although several definitions exist for these terms, in the field of hepatology, sarcopenia has commonly been defined as loss of muscle mass, and frailty has been broadly defined as the phenotypic manifestation of the loss of muscle function. Prompt recognition and accurate assessment of these conditions are critical as they are both strongly associated with morbidity, mortality, poor quality of life and worse post-liver transplant outcomes in patients with cirrhosis. In this review, we describe the complex pathophysiology that underlies the clinical phenotypes of sarcopenia and frailty, their association with decompensation, and provide an overview of tools to assess these conditions in patients with cirrhosis. When available, we highlight data focusing on patients with acutely decompensated cirrhosis, such as inpatients, as this is an area of unmet clinical need. Finally, we discuss management strategies to reverse and/or prevent the development of sarcopenia and frailty, which include adequate nutritional intake of calories and protein, as well as regular exercise of at least moderate intensity, with a mix of aerobic and resistance training. Key knowledge gaps in our understanding of sarcopenia and frailty in decompensated cirrhosis remain, including best methods to measure muscle mass and function in the inpatient setting, racial/ethnic variation in the development and presentation of sarcopenia and frailty, and optimal clinical metrics to assess response to therapeutic interventions that translate into a reduction in adverse outcomes associated with these conditions.

Hospice care for end stage liver disease in the United States

INTRODUCTION

Patients with end-stage liver disease (ESLD) have impaired physical, psychological, and social functions, which can diminish patient quality of life, burden family caregivers, and increase health-care utilization. For those with a life expectancy of less than six months, these impairments and their downstream effects can be addressed effectively through high-quality hospice care, delivered by multidisciplinary teams and focused on the physical, emotional, social, and spiritual wellbeing of patients and caregivers, with a goal of improving quality of life.

AREAS COVERED

In this review, we examine the evidence supporting hospice for ESLD, we compare this evidence to that supporting hospice more broadly, and we identify potential criteria that may be useful in determining hospice appropriateness.

EXPERT OPINION

Despite the potential for hospice to improve care for those at the end of life, it is underutilized for patients with ESLD. Increasing the appropriate utilization of hospice for ESLD requires a better understanding of patient eligibility, which can be based on predictors of high short-term mortality and liver transplant ineligibility. Such hospice criteria should be data-driven and should accommodate the uncertainty faced by patients and physicians.

Drug-loaded lipid microspheres combined with transcatheter arterial chemoembolization for treatment of hepatocellular carcinoma in elderly patients: Efficacy and impact on survival benefit and PD-L1 and PD-1 levels

BACKGROUND

Traditional hepatic artery embolization chemotherapy for treatment of liver cancer is often associated with an unsatisfactory prognosis since the tumor cells remain. Drug-loaded lipid microspheres can assist in further killing residual cancer cells and play an important role in the regulation of PD-1 and PD-L1 in the immune response.

AIM

To evaluate the efficacy of drug-loaded lipid microspheres combined with transcatheter arterial chemoembolization in the treatment of hepatocellular carcinoma in elderly patients, and to analyze its effect on the survival benefit and programmed death-1 ligand (PD-L1) and programmed death 1 (PD-1) levels.

METHODS

From October 2015 to October 2018, 112 elderly patients with hepatocellular carcinoma treated at our hospital were selected. According to the principle of controlled design, the patients were randomly divided into either an observation group (n = 56) or a control group (n = 56). The control group received traditional transcatheter arterial chemoembolization, and the observation group received HepaSphere drug-loaded lipid microspheres combined with transcatheter arterial chemoembolization. The efficacy and serum tumor markers [alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), carbohydrate antigen 199 (CA199), thymidine kinase 1 (TK-1)], tumor angiogenesis-related indicators [vascular endothelial cell growth factor (VEGF), basic fibroblast growth factor (bFGF), and microvessel density (MVD)], and tissue PD-L1 and PD-1 levels were compared between the two groups. The adverse reactions during the treatment period and the survival status of the two groups at 6 mo, 1 year, and 2 years after treatment were also recorded.

RESULTS

The total effective rate in the observation group was 83.93%, which was higher than that (67.86%) of the control group (P < 0.05). Compared with the values before treatment, serum AFP, CEA, CA199, and TK-1 levels in the two groups were significantly reduced after treatment; these tumor markers in the observation group were significantly lower than those of the control group after treatment (P < 0.05). Compared with the values before treatment, the levels of serum VEGF, bFGF, and MVD in the two groups were significantly reduced after treatment; these tumor angiogenesis-related indicators in the observation group were significantly lower than those of the control group (P < 0.05). Compared with the values before treatment, the levels of PD-L1 and PD-1 in the two groups were significantly reduced after treatment; they were also significantly lower in the observation group than in the control group (P < 0.05). During treatment, there was no significant difference in the incidence of nausea, vomiting, abdominal pain, fever, or fatigue between the two groups (P > 0.05). The 1- and 2-year survival rates of the observation group were significantly higher than those of the control group (P < 0.05).

CONCLUSION

Drug-loaded lipid microspheres combined with transcatheter arterial chemoembolization have a significant effect in the treatment of hepatocellular carcinoma in elderly patients, and this combination therapy can effectively inhibit the expression of PD-L1 and PD-1 in cancer tissues and help improve the survival of patients.

Assessment of the Frail Patient With End-Stage Liver Disease: A Practical Overview of Sarcopenia, Physical Function, and Disability

Frailty has emerged as a powerful predictor of clinical outcomes (e.g., decompensation, hospitalization, mortality) in patients with end-stage liver disease (ESLD). It is therefore of paramount importance that all patients with ESLD undergo an assessment of frailty, to support life and death decision making (i.e., candidacy for critical care, transplantation) and aid with prioritization of evolving prehabilitation services (i.e., nutrition, physiotherapy, psychotherapy). This article aims to provide a practical overview of the recent advances in the clinical, radiological, and remote assessment tools of the frail patient with ESLD. Historically, clinicians have incorporated an assessment of frailty using the "end-of-the-bed test" or "eyeball test" into their clinical decision making. However, over the last decade, numerous nonspecific and specific tools have emerged. The current evidence supports the use of a combination of simple, user-friendly, objective measures to first identify frailty in ESLD (notably Clinical Frailty Scale, Liver Frailty Index), followed by a combination of serial tools to assess specifically sarcopenia (i.e., muscle ultrasound), physical function (i.e., chair stands, hand grip strength), functional capacity (i.e., 6-minute walk test), and physical disability (i.e., activities of daily living).

Life Expectancy After Liver Transplantation for Hepatocellular Carcinoma With Cirrhosis

BACKGROUND

Hepatocelluar carcinoma, the most common primary liver cancer, has a historically dire prognosis. For hepatic cancer patients with cirrhosis who underwent liver transplantation, we sought to calculate life expectancies both at time of transplant and several years later, stratified by some key variables, and to determine if survival has improved in recent years.

METHODS

Data on 13,797 hepatic cancer patients with cirrhosis who underwent liver transplantation in the MELD era (2002-2018) from the US Organ Procurement and Transplantation Network database were analyzed using the Cox proportional hazards regression model and life table methods.

RESULTS

The major factors related to survival were age, donor age, transplant year, diabetes, functional status, and the presence of severe hepatic encephalopathy. Survival was significantly worse with increasing age and decreasing functional status level. There was no significant difference in survival between males and females. Survival improved over the study period, at 5% per calendar year during the first 5 years post transplant, and 1% per year thereafter.

CONCLUSIONS

Life expectancies were markedly reduced from normal, even among 5-year survivors with the most favorable characteristics. Survival improved modestly over the years 2002-2018.

Effects of camrelizumab combined with transcatheter arterial chemoembolization arterial chemoembolization on serum Egfl7, VEGF, and OPN levels and recurrence rate in patients with hepatocellular carcinoma with microvascular invasion after radical operation: A prospective study

BACKGROUND

At present, radical resection is still the most effective method for the treatment of patients with liver cancer. Postoperative hepatic transcatheter arterial chemoembolization (TACE) can further remove residual tumor tissue and effectively improve the prognosis of patients. In recent years, targeted therapy of liver cancer has attracted much attention. Programmed-death molecule 1 (PD-1) inhibitors can block the binding of PD-1 to its ligand, thus reactivating T lymphocytes and producing sustained anti-tumor effects to inhibit tumor growth. As a new type of PD-1 inhibitor, carrilizumab has been gradually applied in the clinic.

AIM

To investigate the effect of camrelizumab combined with transcatheter arterial chemoembolization (TACE) on serum epidermal growth factor-like domain 7 (Egfl7), vascular epithelial growth factor (VEGF), and osteopontin (OPN) levels and recurrence rate of patients with hepatocellular carcinoma with microvascular invasion after radical operation.

METHODS

A total of 62 patients with hepatocellular carcinoma with microvascular invasion who were admitted to our hospital from June 2019 to January 2020 were selected. They were divided into either a study group (n = 31) or a control group (n = 31) by simple randomization method. Both groups underwent conventional radical resection of liver cancer. Within 2 mo after surgery, the control group received TACE after surgery, and the study group received camrelizumab + TACE after surgery. Serum levels of tumor markers [carbohydrate antigen 199 (CA199), alpha-fetoprotein (AFP), and carcinoembryonic antigen (CEA)], immune function indicators (CD3⁺, CD4⁺, and CD4⁺/CD8⁺), serum levels of Egfl7, VEGF, and OPN, pain degree (VAS), and quality of life (QOL-LC) before treatment and 1 mo and 3 mo after treatment were compared between the two groups. The incidence of adverse reactions in the two groups and the recurrence rate at 3 mo and 6 mo after the end of treatment were also calculated.

RESULTS

At 1 mo and 3 mo after treatment, serum levels of CA199, AFP, and CEA in the study group were significantly lower than those in the control group (P < 0.05); CD3⁺, CD4⁺, and CD4⁺/CD8⁺ ratio in the study group were significantly higher than those in the control group (P < 0.05); serum Egfl7, VEGF, and OPN levels in the study group were significantly lower than those in the control group (P < 0.05); and the VAS score of the study group was significantly lower than that of the control group, and the QOL-LC score was significantly higher than that of the control group (P < 0.05). The incidence of reactive capillary hyperplasia (61.29%) in the study group was higher than that in the control group (0.00%) (P < 0.05). Compared with the values of the control group (13.33% and 23.33%), the recurrence rates (6.45% and 9.68%) of the study group at 3 mo and 6 mo after radical operation were not statistically significant (P > 0.05).

CONCLUSION

Camrelizumab combined with TACE for hepatocellular carcinoma patients with microvascular invasion after radical resection can further lower serum tumor marker levels and improve cellular immune function, effectively regulate serum Egfl7, VEGF, and OPN levels, reduce the degree of pain, and improve the quality of life. Although the addition of carrelizumab significantly increases the incidence of adverse reactions, they are minor and well tolerated by the patients.

Evaluation and selection of the liver transplant candidate: updates on a dynamic and evolving process

PURPOSE OF REVIEW

Although conceptually unchanged, the evaluation and selection of the liver transplant candidate has seen significant recent advances. Expanding criteria for transplant candidacy, improved diagnostics for risk stratification and advances in prognostic models have paralleled recent changes in allocation and distribution that require us to revisit core concepts of candidate evaluation and selection while recognizing its now dynamic and continuous nature.

RECENT FINDINGS

The liver transplant evaluation revolves around three interrelated themes: candidate selection, donor selection and transplant outcome. Introduction of dynamic frailty indices, bariatric surgery at the time of liver transplant in obese patients and improved therapies and prognostic tools for hepatobiliary malignancy have transformed candidate selection. Advances in hypothermic organ preservation have improved outcomes in marginal donor organs. Combined with expansion of hepatitis C virus positive and split donor organs, donor selection has become an integral part of candidate evaluation. In addition, with liver transplant for acute alcohol-related hepatitis now widely performed and increasing recognition of acute-on-chronic liver failure, selection of critically ill patients is refining tools to balance futility versus utility.

SUMMARY

Advances in liver transplant candidate evaluation continue to transform the evaluation process and require continued incorporation into our clinical practice amidst a dynamic backdrop of demographic and policy changes.

Evaluating the Associations Between the Liver Frailty Index and Karnofsky Performance Status With Waitlist Mortality

Frailty has emerged as a critical determinant of mortality in patients with cirrhosis. Currently, the United Network for Organ Sharing registry only includes the Karnofsky Performance Status (KPS) scale, which captures a single component of frailty. We determined the associations between frailty, as measured by the Liver Frailty Index (LFI), and KPS with waitlist mortality.

Two weeks of hydrogen inhalation can significantly reverse adaptive and innate immune system senescence patients with advanced non-small cell lung cancer: a self-controlled study

Following standard treatments, the traditional model for enhancing anti-tumor immunity involves performing immune reconstitution (e.g., adoptive immune cell therapies or immunoenhancing drugs) to prevent recurrence. For patients with advanced non-small cell lung cancer, we report here on two objectives, the immunosenescence for advanced non-small cell lung cancer and hydrogen gas inhalation for immune reconstitution. From July 1^st to September 25^th, 2019, 20 non-small cell lung cancer patients were enrolled to evaluate the immunosenescence of peripheral blood lymphocyte subsets, including T cell, natural killer/natural killer T cell and gamma delta T cell. Two weeks of hydrogen inhalation was performed during the waiting period for treatment-related examination. All patients inhaled a mixture of hydrogen (66.7%) and oxygen (33.3%) with a gas flow rate of 3 L/min for 4 hours each day. None of the patients received any standard treatment during the hydrogen inhalation period. After pretreatment testing, major indexes of immunosenescence were observed. The abnormally higher indexes included exhausted cytotoxic T cells, senescent cytotoxic T cells, and killer Vδ1 cells. After 2 weeks of hydrogen therapy, the number of exhausted and senescent cytotoxic T cells decreased to within the normal range, and there was an increase in killer Vδ1 cells. The abnormally lower indexes included functional helper and cytotoxic T cells, Th1, total natural killer T cells, natural killer, and Vδ2 cells. After 2 weeks of hydrogen therapy, all six cell subsets increased to within the normal range. The current data indicate that the immunosenescence of advanced non-small cell lung cancer involves nearly all lymphocyte subsets, and 2 weeks of hydrogen treatment can significantly improve most of these indexes. The study was approved by the Ethics Committee of Fuda Cancer Hospital, Jinan University in China (approval No. Fuda20181207) on December 7^th, 2018, and was registered on ClinicalTrials.gov (ID: NCT03818347) on January 24^th, 2019.

Karnofsky performance status predicts outcomes in candidates for simultaneous liver-kidney transplant

Karnofsky performance status (KPS), a measure of physical frailty, predicts pre-transplant and post-transplant outcomes in liver transplantation, but has not been assessed in simultaneous liver-kidney transplantation (SLKT). We examined the association between KPS and outcomes in SLKT waitlist registrants and recipients (2005-2018) in the UNOS database. KPS was categorized into A (able to work), B (able to provide self-care), and C (unable to provide self-care). Cox regression and competing risk analysis were used to assess the association between KPS groups and outcomes. A total of 10,785 patients were waitlisted (KPS: 19% A, 46% B, 35% C), and 5,516 underwent SLKT (12% A, 36% B, 52% C). One-year waitlist mortality was 17%, 22%, and 32% for KPS A, B, and C, respectively. In adjusted competing risk regression, KPS C was associated with increased waitlist mortality (SHR 1.15, 95%CI 1.04-1.28). One-year post-transplant survival was 92%, 91%, and 87% for KPS A, B, and C, respectively. In adjusted Cox regression, KPS C was associated with increased post-transplant mortality (HR 1.32, 95%CI 1.08-1.61). It was also associated with increased liver and kidney graft losses and with hospital length of stay. Frailty, as assessed by KPS, is associated with poor outcomes in SLKT pre- and post-transplant.

Outcome of hepatitis C-related liver transplantation in direct-acting antiviral era

BACKGROUND

Hepatitis C virus (HCV) has become an easily treatable disease after the introduction of sofosbuvir-based direct-acting antiviral (DAA) regimens. This is a large single center experience of changing severity and outcome profile of HCV-related liver disease after availability of DAAs.

METHODS

A retrospective analysis of prospectively collected liver transplantation (LT) database of adults (age > 18 years at the time of LT) was performed from June 2010 to July 2018. A total of 410 patients (including 26 co-infection with hepatitis B) underwent LT for hepatitis C-related decompensated cirrhosis and/or hepatocellular carcinoma (HCC) out of 1754 adult transplantation in the defined period.

RESULTS

The study group comprised of 296 males and 114 females aged 52.1 ± 7.9 years. HCV-related decompensated cirrhosis and/or HCC as indication of LT was present in 289/1016 (28.4%) during 2010-2014, which was reduced to 121/738 (16.3%) during 2015-2018 (p = 0.000). The LT recipients for HCV-related cirrhosis had significantly lower Child's and model for end-stage liver disease (MELD) score during 2015-2018 as compared to that during 2010-2014; Child's score was 7.9 ± 2.2 vs. 8.6 ± 2.1, p = 0.003; MELD score was 13.9 ± 5.3 vs. 17.1 ± 5.8, p = 0.000, respectively. There was a trend towards better survival in HCV patients during 2015-2018 as compared to that during 2010-2014. Significantly more patients had HCV RNA negative status before LT during 2015-2018 (38.8% vs. 13%, p = 0.000); moreover, the proportion of LT for decompensated cirrhosis (without HCC) decreased significantly in the latter period, 64.0% vs. 42.1% (p = 0.000).

CONCLUSION

In the DAA era, HCV as an indication for LT has decreased and patients have less severe disease at transplantation. There is a trend towards better patient survival.

Validating a Patient-Reported Outcomes-Derived Algorithm for Classifying Symptom Complexity Levels Among Patients With Cancer

BACKGROUND

The patient-reported outcomes (PROs) symptom complexity algorithm, derived from self-reported symptom scores using the Edmonton Symptom Assessment System and concerns indicated on the Canadian Problem Checklist, has not been validated extensively.

METHODS

This is a retrospective chart review study using data from the Alberta Cancer Registry and electronic medical records from Alberta Health Services. The sample includes patients with cancer who visited a cancer facility in Alberta, Canada, from February 2016 through November 2017 (n=1,466).

RESULTS

The effect size (d=1.2) indicates that the magnitude of difference in health status between the severe- and low-complexity groups is large. The symptom complexity algorithm effectively classified subgroups of patients with cancer with distinct health status. Using Karnofsky performance status, the algorithm shows a sensitivity of 70.3%, specificity of 84.1%, positive predictive value of 79.1%, negative predictive value of 76.7%, and accuracy of 77.7%. An area under the receiver operating characteristic of 0.824 was found for the complexity algorithm, which is generally regarded as good, This same finding was also regarded as superior to the alternative algorithm generated by 2-step cluster analysis (area under the curve, 0.721).

CONCLUSIONS

The validity of the PRO-derived symptom complexity algorithm is established in this study. The algorithm demonstrated satisfactory accuracy against a clinician-driven complexity assessment and a strong correlation with the known group analysis. Furthermore, the algorithm showed a higher screening capacity compared with the algorithm generated from 2-step cluster analysis, reinforcing the importance of contextualization when classifying patients' symptoms, rather than purely relying on statistical outcomes. The algorithm carries importance in clinical settings, acting as a symptom complexity flag, helping healthcare teams identify which patients may need more timely, targeted, and individualized patient symptom management.

Transplant Outcomes in Older Patients With Nonalcoholic Steatohepatitis Compared to Alcohol-related Liver Disease and Hepatitis C

BACKGROUND

Patients with nonalcoholic steatohepatitis (NASH) are waitlisted at older ages than individuals with other liver diseases, but the effect of age on liver transplantation (LT) outcomes in this population and whether it differs from other etiologies is not known. We aimed to evaluate the impact of age on LT outcomes in NASH.

METHODS

The United Network for Organ Sharing database was used to identify adults with NASH, hepatitis C virus (HCV) infection, and alcohol-related liver disease (ALD) listed for LT during 2004-2017. Patients were split into age groups (18-49, 50-54, 55-59, 60-64, 65-69, ≥70), and their outcomes were compared.

RESULTS

From 2004 to 2017, 14 197 adults with NASH were waitlisted, and the proportion ≥65 increased from 15.8% to 28.9%. NASH patients ages 65-69 had an increased risk of waitlist and posttransplant mortality compared to younger groups, whereas the outcomes in ages 60-64 and 55-59 were similar. The outcomes of individuals with NASH were similar to patients of the same age group with ALD or HCV. Functional status and dialysis were predictors of posttransplant mortality in individuals ≥65 with NASH, and cardiovascular disease was the leading cause of death.

CONCLUSIONS

Older NASH patients (≥65) have an increased risk of waitlist and posttransplant mortality compared to younger individuals, although outcomes were similar to patients with ALD or HCV of corresponding age. These individuals should be carefully evaluated prior to LT, considering their functional status, renal function, and cardiovascular risk. Further studies are needed to optimize outcomes in this growing population of transplant candidates.

Assessing the Time-Dependent Impact of Performance Status on Outcomes After Liver Transplantation

BACKGROUND AND AIMS

Identifying how the prognostic impact of performance status (PS) differs according to indication, era, and time period ("epoch") after liver transplantation (LT) could have implications for selection and treatment of patients on the waitlist. We used national data from the United Kingdom and Ireland to assess impact of PS on mortality separately for HCC and non-HCC recipients.

APPROACH AND RESULTS

We assessed pre-LT PS using the 5-point modified Eastern Cooperative Oncology Group scale and used Cox regression methods to estimate hazard ratios (HRs) that compared posttransplantation mortality in different epochs of follow-up (0-90 days and 90 days to 1 year) and in different eras of transplantation (1995-2005 and 2006-2016). 2107 HCC and 10,693 non-HCC patients were included. One-year survival decreased with worsening PS in non-HCC recipients where 1-year survival was 91.9% (95% confidence interval [CI], 88.3-94.4) in those able to carry out normal activity (PS1) compared to 78.7% (95% CI, 76.7-80.5) in those completely reliant on care (PS5). For HCC patients, these estimates were 89.9% (95% CI, 85.4-93.2) and 83.1% (95% CI, 61.0-93.3), respectively. Reduction in survival in non-HCC patients with poorer PS was in the first 90 days after transplant, with no major effect observed between 90 days and 1 year. Adjustment for donor and recipient characteristics did not change the findings. Comparing era, post-LT mortality improved for HCC (adjusted HR, 0.55; 95% CI, 0.40-0.74) and non-HCC recipients (0.48; 95% CI, 0.42-0.55), but this did not differ according to PS score (P = 0.39 and 0.61, respectively).

CONCLUSIONS

Impact on mortality of the recipient's pretransplant PS is principally limited to the first 3 months after LT. Over time, mortality has improved for both HCC and non-HCC recipients and across the full range of PS.

Patients with Alcoholic Liver Disease Have Worse Functional Status at Time of Liver Transplant Registration and Greater Waitlist and Post-transplant Mortality Which Is Compounded by Older Age

BACKGROUND

Worse functional status correlates with increased mortality on the liver transplant (LT) waitlist. Whether functional status affects LT outcomes equally across cirrhosis etiologies is unclear.

AIMS

We evaluate the impact of functional status on waitlist and post-LT mortality stratified by etiology and age.

METHODS

Functional status among US adults from 2005 to 2017 United Network for Organ Sharing LT registry data was retrospectively evaluated using Karnofsky Performance Status Score (KPS-1 = functional status 80-100%, KPS-2 = 60-70%, KPS-3 = 40-50%, KPS-4 = 10-30%). Waitlist and post-LT survival were stratified by KPS and cirrhosis etiology, including alcoholic liver disease (ALD), nonalcoholic steatohepatitis (NASH), hepatitis C (HCV), and HCV/ALD, and evaluated using Kaplan-Meier and multivariate Cox proportional hazard models.

RESULTS

Among 94,201 waitlist registrants (69.4% men, 39.5% HCV, 26.7% ALD, 23.2% NASH), ALD patients had worse functional status compared to HCV (KPS-4: 17.2% vs. 8.3%, p < 0.001). Worse functional status at time of waitlist registration was associated with higher 90-day waitlist mortality with the greatest effect in ALD (KPS-4 vs. KPS-1: ALD HR 2.16, 95% CI 1.83-2.55; HCV HR 2.17, 95% CI 1.87-2.51). Similar trends occurred in 5-year post-LT survival with ALD patients the most harmed. Compared to patients < 50 years, patients ≥ 65 years had increased waitlist mortality at 90-days if they had HCV or HCV/ALD, and 5-year post-LT mortality regardless of cirrhosis etiology with ALD patients most severely affected.

CONCLUSIONS

In a retrospective cohort study of patients, US ALD patients had disparately worse functional status at time of LT waitlist registration. Worse functional status correlated with higher risk of waitlist and post-LT mortality, affecting ALD and HCV patients the most.

Poor Performance Status Predicts Mortality After Living Donor Liver Transplantation

BACKGROUND/AIMS

Performance status may adversely affect living donor liver transplantation (LDLT) outcomes. We present our data regarding performance status and posttransplantation survival in a large LDLT cohort.

METHODS

Patients with ABO incompatibility, of pediatric age, with acute liver failure, with hepatocellular carcinoma, and/or who had incomplete data were excluded. Two hundred sixty adults who had decompensated cirrhosis and underwent LDLT from January 2016 to March 2018 were included. Performance status was assessed by Karnofsky Performance Score (KPS). The data are depicted as number, mean (SD), or median (25-75 interquartile range [IQR]).

RESULTS

The cohort included 232 males and 28 females, aged 48.3 ± 9.8 years. Etiology of liver disease was hepatitis B in 33, hepatitis C in 19, alcohol related in 120, nonalcoholic steatohepatitis/cryptogenic in 68, and other etiologies in 20 patients. The mean Child's score was 9.6 ± 1.7, Model for End-Stage Liver Disease (MELD) score was 18.0 ± 5.8, and donor age was 33.4 ± 9.9 years. Forty-one recipients died at median follow-up of 11 months. The KPS was 100 in 6 (no deaths), 90 in 53 (2 deaths), 80 in 93 (12 deaths), 70 in 69 (14 deaths), 60 in 26 (8 deaths), and 50 in 13 (5 deaths) (P = 0.003). The area under the receiver operating characteristic curve of KPS to predict mortality was 0.698 (P = 0.000, 95% confidence interval [CI] = 0.616-0.780), and the best sensitivity (63%) and specificity (67%) were achieved at KPS ≤70. The survivors and nonsurvivors had a significant difference with respect to KPS (77.6 ± 10.9 versus 69.5 ± 10.9, P 0.000), age of the patient (47.8 ± 9.4 versus 51.1 ± 11.7; P = 0.047), postoperative infections (53.8% versus 85.3%, P = 0.001), and need of packed red cells transfusion. Multivariate analysis (Cox proportional-hazard) showed KPS (hazard ratio [HR] = 0.96, 95% CI = 0.93-0.99, P = 0.007), postoperative infections (HR = 2.3, 95% CI = 1.04-5.1, P = 0.038), and recipient age (HR = 1.03, 95% CI = 1.002-1.07, P = 0.039) as predictors of mortality.

CONCLUSION

Pretransplant performance status is one of the predictors of mortality after LDLT.

Karnofsky Performance Status Following Liver Transplantation in Patients With Multiple Organ Failures and Probable Acute-on-Chronic Liver Failure

BACKGROUND & AIMS

Little is known about outcomes of patients who underwent liver transplantation for acute on chronic liver failure (ACLF) and multiple organ failures. We compared Karnofsky Performance Status (KPS) before and after liver transplantation among patients with different numbers of organ failures and probable ACLF.

METHODS

We performed a retrospective cohort study of adults who underwent liver transplantation within 30 days of listing with the United Network for Organ Sharing (UNOS) network from January 1, 2006, through September 30, 2016. We determined the prevalence of organ failures using a modified version of the Chronic Liver Failure-Sequential Organ Failure Assessment scale and collected KPS scores at the time of transplantation and at intervals of 3 to 12 months after liver transplantation. Multivariate analyses were performed to adjust for confounders including UNOS region.

RESULTS

At the time of liver transplantation, 2838 patients had no organ failure, 2944 had 1 to 2 organ failures, and 1342 patients had 3 or more organ failures. KPS scores following liver transplantation improved significantly in all groups; scores ranged from 81 in patients with no organ failure to 72 in patients with 5 to 6 organ failures. Excellent performance status (KPS score, ≥80) by 1 year after transplantation was achieved by 60% of patients with 5 to 6 organ failures, 64% to 66% of patients with 3 to 4 organ failures, and 70% to 71% of patients with 1 to 2 organ failures, compared with 72.5% of patients without organ failure. Patients with 1 to 4 organ failure were more likely to achieve KPS scores of 80 or more than patients without organ failure, after we adjusted for other covariates and UNOS region. In addition, black patients were less likely, and patients with alcoholic cirrhosis were more likely, to have KPS scores of 80 or more after liver transplantation.

CONCLUSIONS

In a retrospective cohort study of patients with probable ACLF who underwent liver transplantation within 30 days of listing with the UNOS network, 60% to 66% of patients with 3 or more organ failures achieved excellent performance 3 to 12 months later.