Model for end-stage liver disease can predict very early outcome after liver transplantation

Perioperative predictors for refractory hyperglycemia during the neohepatic phase of liver transplantation

BACKGROUND

Hyperglycemia in the neohepatic phase of liver transplantation (LT) tends to decrease toward completion of the surgical procedure. Refractory hyperglycemia in the neohepatic phase (RH) is influenced by multiple perioperative factors and may be connected to posttransplant outcomes. We attempted to demonstrate the relationship of RH to posttransplant outcomes and to establish a predictive model for RH in living donor liver transplantation (LDLT).

METHODS

Perioperative data of 211 patients who underwent LDLT from 2009 and 2012 were reviewed, including declines in the blood glucose levels during the neohepatic phase. Perioperative variables including the posttransplant model for end-stage liver disease (MELD) score until day 30 were compared between patients with normal declines in blood glucose and patients with RH. Selected variables after intergroup comparisons were examined by means of multivariate logistic regression to establish a predictive model for RH occurrence.

RESULTS

The mean blood glucose decline was 22.3 ± 31.5 mg/dL during the neohepatic phase, and 84 of 203 patients (41.4%) had no decline in blood glucose. In intergroup comparisons, preoperative factors associated with RH included sex, Child-Pugh-Turcotte class, MELD score, emergency, liver enzymes, and graft-to-recipient weight ratio. During surgery, surgical time, serum lactate, and arterial pH were associated with RH. After surgery, the RH group showed slower recovery of the MELD score (15.2 versus 11.9 days) and higher MELD scores until day 10 (P < .05). After the multivariate analysis, recipient sex, emergency, surgical time (≤9 h), and the final intraoperative serum lactate level (≥5.0 mmol/L) were included in the predictive model for RH.

CONCLUSIONS

RH was associated with delayed functional recovery of the liver graft in LT. Recipient sex, emergency, surgical time, and the final intraoperative serum lactate level were identified as predictors of RH. Close monitoring of intraoperative blood glucose in LDLT may be an early prognostic indicator.

Factors Associated with Mortality and Graft Failure in Liver Transplants: A Hierarchical Approach

BACKGROUND

Liver transplantation has received increased attention in the medical field since the 1980s following the introduction of new immunosuppressants and improved surgical techniques. Currently, transplantation is the treatment of choice for patients with end-stage liver disease, and it has been expanded for other indications. Liver transplantation outcomes depend on donor factors, operating conditions, and the disease stage of the recipient. A retrospective cohort was studied to identify mortality and graft failure rates and their associated factors. All adult liver transplants performed in the state of São Paulo, Brazil, between 2006 and 2012 were studied.

METHODS AND FINDINGS

A hierarchical Poisson multiple regression model was used to analyze factors related to mortality and graft failure in liver transplants. A total of 2,666 patients, 18 years or older, (1,482 males; 1,184 females) were investigated. Outcome variables included mortality and graft failure rates, which were grouped into a single binary variable called negative outcome rate. Additionally, donor clinical, laboratory, intensive care, and organ characteristics and recipient clinical data were analyzed. The mortality rate was 16.2 per 100 person-years (py) (95% CI: 15.1-17.3), and the graft failure rate was 1.8 per 100 py (95% CI: 1.5-2.2). Thus, the negative outcome rate was 18.0 per 100 py (95% CI: 16.9-19.2). The best risk model demonstrated that recipient creatinine ≥ 2.11 mg/dl [RR = 1.80 (95% CI: 1.56-2.08)], total bilirubin ≥ 2.11 mg/dl [RR = 1.48 (95% CI: 1.27-1.72)], Na+ ≥ 141.01 mg/dl [RR = 1.70 (95% CI: 1.47-1.97)], RNI ≥ 2.71 [RR = 1.64 (95% CI: 1.41-1.90)], body surface ≥ 1.98 [RR = 0.81 (95% CI: 0.68-0.97)] and donor age ≥ 54 years [RR = 1.28 (95% CI: 1.11-1.48)], male gender [RR = 1.19(95% CI: 1.03-1.37)], dobutamine use [RR = 0.54 (95% CI: 0.36-0.82)] and intubation ≥ 6 days [RR = 1.16 (95% CI: 1.10-1.34)] affected the negative outcome rate.

CONCLUSIONS

The current study confirms that both donor and recipient characteristics must be considered in post-transplant outcomes and prognostic scores. Our data demonstrated that recipient characteristics have a greater impact on post-transplant outcomes than donor characteristics. This new concept makes liver transplant teams to rethink about the limits in a MELD allocation system, with many teams competing with each other. The results suggest that although we have some concerns about the donors features, the recipient factors were heaviest predictors for bad outcomes.

13C-aminopyrine demethylation is decreased in cirrhotic patients with normal biochemical markers

This study determined the rates of (13)C-aminopyrine metabolism in patients with varying degrees of liver cirrhosis as defined by clinical scores. Twenty-five cirrhotic patients and 18 healthy subjects underwent a (13)C-aminopyrine breath test. The cumulative per cent dose recovery (cPDR) of (13)C on breath expressed as a percentage of the administered dose at 2 h was significantly lower in cirrhotic patients than in healthy subjects (median: 1.7% versus 9.0%; p<.0001). Significant inverse associations between cPDR at 2 h and the model for end-stage liver disease score, Child-Pugh score, international normalised ratio and bilirubin (all p<.05), but not alanine aminotransferase or alkaline phosphatase were observed in the cirrhotic patients. Taking each biochemical marker independently, cirrhotic patients with normal biochemistry had a significantly lower cPDR at 2 h than healthy subjects (all p<.05). Differences in (13)C-aminopyrine metabolism were evident in cirrhotic patients with less severe disease and may mark hepatic dysfunction when conventional biochemical markers appear unchanged.

Predictors of early graft survival after pediatric liver transplantation

The objective of this study was to identify peritransplant predictors of early graft survival and posttransplant parameters that could be used to predict early graft outcomes after pediatric liver transplantation (PLT). The response of children to liver dysfunction after liver transplantation (LT) is poor. No data have been reported for early predictors of poor graft survival, which would potentially be valuable for rescuing children at risk after LT. A retrospective cohort study of 422 PLT procedures performed from 2000 to 2010 at a single center was conducted. Multiple peritransplant variables were analyzed. Univariate and multivariate analyses using receiver operating characteristic curves were performed to identify predictors of early graft loss (ie, at 30, 60, and 90 days). The number needed to treat (NNT) was calculated when the risk factors were identified. Comparisons with the Olthoff criteria for early graft dysfunction in adults were performed. The overall 30-, 60-, and 90-day graft survival rates were 93.6%, 92.6%, and 90.7%, respectively. A recipient age of 0 to 2 or 6 to 16 years, acute liver failure, and a posttransplant day 7 serum bilirubin level > 200 μmol/L were risk factors for graft loss in the 3-strata Cox models. The product of the peak aspartate aminotransferase (AST) level, day 2 international normalized ratio (INR) value, and day 7 bilirubin level [with 30-, 60-, and 90-day areas under the receiver operating characteristic curve (AUROCs) of 0.774, 0.752, and 0.715, respectively] and a day 7 bilirubin level > 200 μmol/L (with 30-, 60-, and 90-day AUROCs of 0.754, 0.661, and 0.635, respectively) provided excellent prediction rates for early graft loss (30-days for Day-7-bilirubin level > 200) in the pediatric population (sensitivity = 72.7%, specificity = 96.6%, positive predictive value = 95.5%, negative predictive value = 78%). The NNT with early retransplantation when the day 7 bilirubin level was >200 μmol/L was 2.17 (unadjusted) or 2.76 (adjusted for graft survival). In conclusion, 2 scores-the product of the peak AST level, day 2 INR value, and day 7 bilirubin level and a posttransplant day 7 bilirubin level > 200 μmol/L-have been identified as clinically valuable tools with high accuracy for predicting early graft loss. A more aggressive attitude to considering early retransplantation in this group may further improve survival after LT.

Sluggish decline in a post-transplant model for end-stage liver disease score is a predictor of mortality in living donor liver transplantation

Background

The pre-transplant model for end-stage liver disease (pre-MELD) score is controversial regarding its ability to predict patient mortality after liver transplantation (LT). Prominent changes in physical conditions through the surgery may require a post-transplant indicator for better mortality prediction. We aimed to investigate whether the post-transplant MELD (post-MELD) score can be a predictor of 1-year mortality.

Methods

Perioperative variables of 269 patients with living donor LT were retrospectively investigated on their association with 1-year mortality. Post-MELD scores until the 30th day and their respective declines from the 1st day post-MELD score were included along with pre-MELD, acute physiology and chronic health evaluation (APACHE) II, and sequential organ failure assessment (SOFA) scores on the 1st post-transplant day. The predictive model of mortality was established by multivariate Cox's proportional hazards regression.

Results

The 1-year mortality rate was 17% (n = 44), and the leading cause of death was graft failure. Among prognostic indicators, only post-MELD scores after the 5th day and declines in post-MELD scores until the 5th and 30th day were associated with mortality in univariate analyses (P < 0.05). After multivariate analyses, declines in post-MELD scores until the 5th day of less than 5 points (hazard ratio 2.35, P = 0.007) and prolonged mechanical ventilation ≥24 hours were the earliest independent predictors of 1-year mortality.

Conclusions

A sluggish decline in post-MELD scores during the early post-transplant period may be a meaningful prognostic indicator of 1-year mortality after LT.

[The value of MELD in the allocation of priority for liver transplantation candidates]

Liver transplantation is the most effective treatment for many patients with chronic end-stage liver disease. The discrepancy between the number of donor organs and potential recipients causes marked pre-transplantation mortality and consequently optimal rationalization of organ allocation is essential. The Model for End-Stage Liver Disease (MELD) is an objective and easily reproducible prognostic index of mortality based on three simple analytical variables: bilirubin and serum creatinine and the prothrombin time/International Normalized Ratio (INR) of protrombine time. The implementation of MELD as an organ allocation system has reduced mortality on the waiting list without affecting post-transplantation survival. Nevertheless, this model has some limitations and consequently further investigations should be performed to improve the organ allocation policy in liver transplantation.

Values of end-stage liver disease model in assessment of prognosis in patients with decompensated liver cirrhosis

AIM: To compare the prognostic values of for end-stage liver disease (MELD) model and Child-Turcotte-Pugh (CTP) for patients with decompensated liver cirrhosis.

METHODS: From a previously collected database, 203 patients with decompensated liver cirrhosis admitted to our hospital were studied and followed up at least for one year. MELD and CTP score and classification were calculated on entry. Receiver operating characteristics curves (ROC) and the area under ROC were used to determine the ability of the scores for predicting three, six and twelve month mortality. Kaplan-Meier survival analysis (K-M) was performed using the cut-offs to establish the predictive power of each score.

RESULTS: There were 23, 39 and 85 dead cases within 3, 6 and 12 mo respectively. There was a significant correlation between the MELD and CTP score in 3, 6 and 12 mo (r = 0.76, 0.69, 0.71, P < 0.01). The areas under the receiver operating characteristics curves of MELD and CTP for the occurrence of death in 3 mo were 0.886 and 0.775. There was a significant difference in the 3 mo between two scores (P < 0.01). The areas under the receiver operating characteristics curves for MELD was 0.892 compared with 0.876 for CTP at 6 mo (P > 0.05); the area was 0.873 and 0.886 respectively at 12 mo (P > 0.05). Both MELD and CTP scores predicted the death rate and survival rate within 3, 6 and 12 mo by survival analysis (P < 0.01).

CONCLUSION: MELD is a strong prognosis predictor for the decompensated liver cirrhosis. MELD was significantly better than CTP score for predicting in-hospital mortality in 3 mo. However, these are not superior to CTP score and CTP classification in 6 and 12 mo.