Liver Transplantation for Acute Liver Failure: Trying to Define When Transplantation Is Futile

SOFA in the first 24 hours as an outcome predictor of acute liver failure

OBJECTIVE

To describe a cohort of patients with acute liver failure and to analyze the demographic and clinical factors associated with mortality.

METHODS

Retrospective cohort study in which all patients admitted for acute liver failure from July 28, 2012, to August 31, 2017, were included. Clinical and demographic data were collected using the Epimed System. The SAPS 3, SOFA, and MELD scores were measured. The odds ratios and 95% confidence intervals were estimated. Receiver operating characteristics curves were obtained for the prognostic scores, along with the Kaplan-Meier survival curve for the score best predicting mortality.

RESULTS

The majority of the 40 patients were female (77.5%), and the most frequent etiology was hepatitis B (n = 13). Only 35% of the patients underwent liver transplantation. The in-hospital mortality rate was 57.5% (95%CI: 41.5 - 73.5). Among the scores investigated, only SOFA remained associated with risk of death (OR = 1.37; 95%CI 1.11 - 1.69; p < 0.001). After SOFA stratification into < 12 and ≥ 12 points, survival was higher in patients with SOFA <12 (log-rank p < 0.001).

CONCLUSION

SOFA score in the first 24 hours was the best predictor of fatal outcome.

Acute Liver Failure-25 Years at a Single Center: Role of Liver Transplantation in the Survival of Adult Patients

BACKGROUND

Acute liver failure (ALF) leads to high morbidity and mortality and is characterized by an accelerated deterioration of hepatic function in patients without prior liver disease. The survival rate is <15% without liver transplantation (LT). The aim of this study was to describe the population of patients with ALF in the Unit of Liver Transplantation of the University of Campinas, Brazil, from 1991 to 2017, comparing those submitted and not submitted to LT.

METHODS

The patients were divided into 2 groups: 1, listed but not transplanted; and 2, transplanted.

RESULTS

There were 73 patients with ALF listed for LT, with a mean age of 33.6 years, 49 (67.1%) female and 24 (32.9%) male. Group 1, with 32 patients, had a mean age of 29.3 years; 26 (81.25%) died on the waiting list; 6 (8.45%), with a mean age of 12.33 years, were removed from the list because of recovery of liver function. Considering only adult patients, the mortality without LT was 96.29%. Group 2 had 41 patients, with a mean age of 37.1 years, and a 30-day survival of 41.02%. Thus, LT led to a significant improvement in the survival of adult patients with ALF. The time of surgery, packed red blood cells, and intraoperative plasma, were associated with LT survival after logistic regression study, whereas age, body mass index, bilirubin, international normalized ratio, creatinine, sodium, and Model for End-Stage Liver Disease score were not.

CONCLUSIONS

ALF affects an active age range, and LT decreases mortality; there was no good preoperative prognostic indicator to assess which patients would benefit from transplantation.

Decade-Long Trends in Liver Transplant Waitlist Removal Due to Illness Severity: The Impact of Centers for Medicare and Medicaid Services Policy

BACKGROUND

The central tenet of liver transplant organ allocation is to prioritize the sickest patients first. However, a 2007 Centers for Medicare and Medicaid Services regulatory policy, Conditions of Participation (COP), which mandates publically reported transplant center performance assessment and outcomes-based auditing, critically altered waitlist management and clinical decision making. We examine the extent to which COP implementation is associated with increased removal of the "sickest" patients from the liver transplant waitlist.

STUDY DESIGN

This study included 90,765 adult (aged 18 years and older) deceased donor liver transplant candidates listed at 102 transplant centers from April 2002 through December 2012 (Scientific Registry of Transplant Recipients). We quantified the effect of COP implementation on trends in waitlist removal due to illness severity and 1-year post-transplant mortality using interrupted time series segmented Poisson regression analysis.

RESULTS

We observed increasing trends in delisting due to illness severity in the setting of comparable demographic and clinical characteristics. Delisting abruptly increased by 16% at the time of COP implementation, and likelihood of being delisted continued to increase by 3% per quarter thereafter, without attenuation (p < 0.001). Results remained consistent after stratifying on key variables (ie, Model for End-Stage Liver Disease and age). The COP did not significantly impact 1-year post-transplant mortality (p = 0.38).

CONCLUSIONS

Although the 2007 Centers for Medicare and Medicaid Services COP policy was a quality initiative designed to improve patient outcomes, in reality, it failed to show beneficial effects in the liver transplant population. Patients who could potentially benefit from transplantation are increasingly being denied this lifesaving procedure while transplant mortality rates remain unaffected. Policy makers and clinicians should strive to balance candidate and recipient needs from a population-benefit perspective when designing performance metrics and during clinical decision making for patients on the waitlist.

Model for End-Stage Liver Disease (MELD) score does not predict outcomes of hepatitis B-induced acute-on-chronic liver failure in transplant recipients

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a severe clinical entity and liver transplantation is the only definitive therapy to salvage these patients. However, the timing of liver transplant for these patients remains unclear.

METHODS

Seventy-eight patients undergoing liver transplantation because of hepatitis B ACLF were retrospectively analyzed from June 2004 to December 2010. The areas under the receiver operating characteristic curve (AUC) of Model for End-Stage Liver Disease (MELD) score and Child-Turcotte-Pugh (CTP) score for the post-transplantation outcomes were calculated.

RESULTS

The median age was 44 years (range, 25-64 years), serum bilirubin 418.53 μmol/L (range, 112.90-971.40 μmol/L), INR 3.177 (range, 1.470-9.850), and creatinine 70.84 μmol/L (range, 12.39-844.1 μmol/L); the median MELD score was 32 (range, 21-53) and CTP score 12 (8-15). The AUCs of MELD and CTP scores for 3-month mortality were 0.581 (95% confidence interval [CI], 0.421-0.742; sensitivity, 87.5%; specificity, 32.8%) and 0.547 (95% CI, 0.401-0.693; sensitivity, 75%; specificity, 41%), respectively. Meanwhile, there were no significant differences in hospital mortality (P = .252) or morbidity (P = .338) between the patients with MELD score ≥30 and those <30.

CONCLUSIONS

MELD score had no predictive ability for the outcomes of patients with hepatitis B ACLF after orthotopic liver transplantation.

http://www.D-MELD.com, the Italian survival calculator to optimize donor to recipient matching and to identify the unsustainable matches in liver transplantation

Optimization of donor-recipient match is one of the exciting challenges in liver transplantation. Using algorithms obtained by the Italian D-MELD study (5256 liver transplants, 21 Centers, 2002-2009 period), a web-based survival calculator was developed. The calculator is available online at the URL http://www.D-MELD.com. The access is free. Registration and authentication are required. The website was developed using PHP scripting language on HTML platform and it is hosted by the web provider Aruba.it. For a given donor (expressed by donor age) and for three potential recipients (expressed by values of bilirubin, creatinine, INR, and by recipient age, HCV, HBV, portal thrombosis, re-transplant status), the website calculates the patient survival at 90days, 1year, 3years, and allows the identification of possible unsustainable matches (i.e. donor-recipient matches with predicted patient survival less than 50% at 5 years). This innovative approach allows the selection of the best recipient for each referred donor, avoiding the allocation of a high-risk graft to a high-risk recipient. The use of the D-MELD.com website can help transplant surgeons, hepatologists, and transplant coordinators in everyday practice of matching donors and recipients, by selecting the more appropriate recipient among various candidates with different prognostic factors.

Balancing donor and recipient risk factors in liver transplantation: the value of D-MELD with particular reference to HCV recipients

Donor-recipient match is a matter of debate in liver transplantation. D-MELD (donor age × recipient biochemical model for end-stage liver disease [MELD]) and other factors were analyzed on a national Italian database recording 5946 liver transplants. Primary endpoint was to determine factors predictive of 3-year patient survival. D-MELD cutoff predictive of 5-year patient survival <50% (5yrsPS<50%) was investigated. A prognosis calculator was implemented (http://www.D-MELD.com). Differences among D-MELD deciles allowed their regrouping into three D-MELD classes (A < 338, B 338-1628, C >1628). At 3 years, the odds ratio (OR) for death was 2.03 (95% confidence interval [CI], 1.44-2.85) in D-MELD class C versus B. The OR was 0.40 (95% CI, 0.24-0.66) in class A versus class B. Other predictors were hepatitis C virus (HCV; OR = 1.42; 95% CI, 1.11-1.81), hepatitis B virus (HBV; OR = 0.69; 95% CI, 0.51-0.93), retransplant (OR = 1.82; 95% CI, 1.16-2.87) and low-volume center (OR = 1.48; 95% CI, 1.11-1.99). Cox regressions up to 90 months confirmed results. The hazard ratio was 1.97 (95% CI, 1.59-2.43) for D-MELD class C versus class B and 0.42 (95% CI, 0.29-0.60) for D-MELD class A versus class B. Recipient age, HCV, HBV and retransplant were also significant. The 5yrsPS<50% cutoff was identified only in HCV patients (D-MELD ≥ 1750). The innovative approach offered by D-MELD and covariates is helpful in predicting outcome after liver transplantation, especially in HCV recipients.

Cytokeratin 18-based modification of the MELD score improves prediction of spontaneous survival after acute liver injury

BACKGROUND & AIMS

Predicting the probability of patients with acute liver failure (ALF) to recover spontaneously is of major clinical importance. As apoptotic and necrotic cell death are crucial in the pathogenesis of ALF, we determined whether selected cell-death markers predict outcome of patients with ALF and/or discriminate between etiologies.

METHODS

In a prospective study (11/2006-06/2009), 68 ALF patients were recruited consecutively. Data were collected over four weeks or until discharge, death or LTx, including CK18/M65 and M30 ELISA and glutathione S-transferase, subtype alpha. Data at date of admission and at the date of peak levels of M65 were individually analyzed and correlated with the patients' prognosis and etiology.

RESULTS

The predictive sensitivity of total serum M65 for lethal outcome was comparable to the Model for End-Stage Liver Disease (MELD) score at time of admission and at its peak value. In contrast, serum bilirubin levels had no prognostic value, neither at admission nor at later time points. In order to accurately predict the clinical prognosis of ALF patients, we tested a modified MELD score where CK18 M65 substituted bilirubin. This CK18/M65-based MELD score significantly better predicted the prognosis of ALF patients compared with the current MELD score or KCC. A combination of tested parameters contributed to improved discrimination of ALF etiologies by applying cell death and established laboratory parameters.

CONCLUSIONS

The CK18 M65-based MELD score has superior sensitivity and specifically predicts survival of ALF patients. Further prospective clinical studies could validate its potential role to predict requirement of LTx in ALF patients.

Analysis of liver transplant outcomes for United Network for Organ Sharing recipients 60 years old or older identifies multiple model for end-stage liver disease-independent prognostic factors

Older recipient age is associated with worse posttransplant survival. Although the median age of liver disease patients undergoing orthotopic liver transplantation (OLT) continues to rise, prognostic factors for posttransplant survival specific to older patients have not been defined. To address this issue, the United Network for Organ Sharing/Organ Procurement and Transplantation Network outcome database was searched to identify prognostic factors for the 8070 liver recipients 60 years old or older who underwent transplantation from 1994 to 2005. Prognostic factors were assessed with univariate analysis and multivariate modeling. The 5 strongest prognostic variables (ventilator status, diabetes mellitus, hepatitis C virus, creatinine levels >/=1.6 mg/dL, and recipient and donor age >or=120 years) were aggregated to define a novel older recipient prognostic score (ORPS). The overall 1- and 5-year posttransplant survival rates were 83% and 67%, respectively. The risk model, created by the assignment of 1 point to each ORPS factor, stratified patient outcomes into distinct prognostic groups at the 1-, 3-, and 5-year posttransplant time points (P < 0.001). The 5-year survival rates for patients with ORPS values of 0, 1, and 2 points were 75%, 69%, and 58%, respectively. Patients who underwent transplantation with an ORPS > 2 points consistently experienced 5-year survival rates of less than 50%. In conclusion, in liver transplant recipients 60 years old or older, the ORPS was able to predict significant and clinically relevant differences in posttransplant survival. By optimization of donor selection for recipients over the age of 60 years, clinical utilization of the ORPS model may enhance organ utilization for all patients awaiting OLT.

Clinical utility of an automated pupillometer for assessing and monitoring recipients of liver transplantation

Pupil examination has been used as a basic measure in critically ill patients and has great importance for the prognosis and management of disease. An automated pupillometer is a computer-based infrared digital video system by which the accuracy and precision of the pupil examination are markedly improved. We conducted an observational study of pupil assessment with automated pupillometry in clinical liver transplantation settings, including pretransplant evaluations and posttransplant surveillance. Our results showed that unconscious patients (grade 4 hepatic encephalopathy) had a prolonged latency phase (left side: 283 +/- 80 milliseconds; right side: 295 +/- 96 milliseconds) and a reduced pupillary constrictive ratio (left direct response: 0.23 +/- 0.10; left indirect response: 0.21 +/- 0.07; right direct response: 0.20 +/- 0.08; right indirect response: 0.21 +/- 0.08) in comparison with normal and conscious patients. After liver transplantation, the recovery of pupillography in these patients was slower than that in conscious patients. However, the surviving recipients without major complications all had a gradual recovery of pupillary responses, which occurred on the first or second posttransplant day. We also reported 4 cases of futile LT in the absence of pretransplant pupillary responses and other pupillary abnormalities revealed by automated pupillometry in our study. In conclusion, patients with grade 4 hepatic encephalopathy had a sluggish pupil response and a delayed recovery pattern after LT. An automated pupillometer is potentially a supplementary device for pretransplant screening and posttransplant monitoring in patients undergoing LT, but further prospective studies are required.

Postoperative issues and outcome for acute liver failure

1. Establishing the cause of fulminant hepatitis is an important determinant in outcomes after liver transplantation. 2. Liver transplantation is an integral part of the management of ALF. 3. In addition to generic posttransplant care, neurologic, septic, and hematologic issues need to be addressed. 4. Outcomes after liver transplantation are poorer than those for elective transplantation but superior to those found for comparably ill patients being transplanted for chronic liver disease. 5. Multiple factors have an influence on outcome, and risk stratification is beginning to emerge.