Predicting short-term survival after liver transplantation on eight score systems: a national report from China Liver Transplant Registry

Novel treatment of acute and acute-on-chronic liver failure: Interleukin-22

Acute liver failure (ALF) is a life-threatening medical condition, characterized by rapidly progressive hepatic dysfunction, coagulopathy and hepatic encephalopathy in patients without chronic liver disease, while acute-on-chronic liver failure (ACLF) occurs in patients with existing chronic liver disease. ALF and ACLF are often associated with multiple organ failure and a high short-term mortality. In this review, we briefly discuss the causes and pathogenesis of ALF and ACLF, the current options available for the treatment of both deadly maladies and interleukin-22 (IL-22), a novel promising drug that may have great therapeutic potential for ALF and ACLF treatment. IL-22 is a cytokine produced by immune cells but mainly targets epithelial cells including hepatocytes. IL-22 has been shown to protect against organ damage and reduce bacterial infection in many preclinical models and several clinical trials including alcohol-associated hepatitis. The potential application of IL-22 for the treatment of ALF and ACLF is also elaborated.

The Association Between Cytomegalovirus Infection and Kidney Damage in the Liver Transplant Setting

INTRODUCTION

The development of chronic kidney disease (CKD) is a common and significant complication, contributing to morbidity after liver transplantation (LT). Cytomegalovirus (CMV) infection is common in the overall population, and relevant reinfection after LT may occur. CMV-associated kidney damage has been discussed, but the clinical significance on CKD development after LT remains unclear.

METHODS

A total of 745 patients who underwent LT between 2006 and 2017 were included in this retrospective analysis. Clinical data, as well as laboratory parameters, were analyzed. Univariate and multivariate analysis were performed.

RESULTS

The univariate analysis revealed significantly impaired estimated glomerular filtration rates (eGFRs) in patients with histories of CMV infection (81.4 (8-137) mL/min vs. 90.0 (5-147) mL/min; p = 0.004). This effect was confirmed in the multivariate analysis. Post-LT, eGFR was impaired in patients with CMV (re)infection at 6, 12, 36, and 60 months, 10 years, and 15 years after LT. Immunosuppressive levels were comparable between groups. Overall survival was negatively affected by CMV infection (p = 0.001).

DISCUSSION

A clinically significant detrimental impact of CMV infection on renal function was observed, that could individualize clinical risk evaluation prior and after LT further. However, the pathophysiological mechanisms behind this observation are not yet understood.

The correlation between the European System for Cardiac Operative Risk Evaluation and the Model for End-Stage Liver Disease in patients with coronary artery bypass graft surgery

The Model for End-Stage Liver Disease (MELD) score is a widely used tool for quantifying hepatic dysfunction, providing greater accuracy and a wider range of values compared to the Child-Turcotte-Pugh (CTP) score, being also used in prioritizing patients who are eligible for liver transplantation. This study assessed the correlation between the MELD score and the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), a reliable system for categorizing risk levels in patients undergoing cardiovascular surgery. This retrospective study analyzed data from 589 patients who underwent coronary artery bypass grafting (CABG) at the Institute of Cardiovascular Diseases 'Prof. Dr. George I.M. Georgescu' in Iași between January 2011 and December 2020. Data collected included demographical, clinical, biochemical, and intraoperative parameters. The average MELD score was 6.09 ± 4.1 (median = 5.72), and the average EuroSCORE II was 6.28 ± 8 (median = 3.85). A significant but relatively modest positive relationship was found between the MELD score and EuroSCORE II, with a correlation coefficient of 0.23 and a corresponding significance level of 0.001. This study demonstrates a positive correlation between MELD and EuroSCORE II in patients who underwent CABG. Incorporating the MELD score into the preoperative risk assessment of cardiac surgery patients could help identify high-risk individuals and guide clinical decision-making.

Risk evaluation and recipient selection in adult liver transplantation: A mixed-methods survey

Background:

Liver transplant (LT) is the definitive treatment for end-stage liver disease. Limited resources and important post-operative implications for recipients compel judicious risk stratification and patient selection. However, little is known about the factors influencing physicians’ assessment regarding patient selection for LT and risk evaluation.

Methods:

We conducted a mixed-methods, cross-sectional survey involving Canadian hepatologists, anesthesiologists, LT surgeons, and French anesthesiologists. The survey contained quantitative questions and a vignette-based qualitative substudy about risk assessment and patient selection for LT. Descriptive statistics and qualitative content analyses were used.

Results:

We obtained answers from 129 physicians, and 63 participated in the qualitative substudy. We observed considerable variability in risk assessment prior to LT and identified many factors perceived to increase the risk of complications. Clinicians reported that the acceptable incidence of at least 1 severe post-operative complication for a LT program was 20% (95% CI: 20-30%). They identified the presence of any comorbidity as increasing the risk of different post-operative complications, especially acute kidney injury and cardiovascular complications. Frailty and functional disorders, severity of the liver disease, renal failure and cardiovascular comorbidities prior to LT emerged as important risk factors for post-operative morbidity. Most respondents were willing to pursue LT in patients with grade III acute-on-chronic liver failure but were less often willing to do so when faced with the uncertainty of a clinical example.

Conclusions:

Clinicians had a heterogeneous appraisal of the post-operative risk of complications following LT, as well as factors considered in risk assessment.

Liver transplantation in Acute-on-Chronic liver failure: Timing of transplantation and selection of patient population

Acute-on-Chronic liver failure (ACLF) is a clinical syndrome with high short-term mortality. Alcoholic ACLF is prevalent in European and American countries, while hepatitis B virus (HBV)-related ACLF is more common in the Asia-Pacific region. There is still a lack of a unified definition standard for ACLF, due to various etiologies and pathogeneses in different continents. Currently, liver transplantation (LT) is the most effective treatment for liver failure. However, the shortage of liver sources is still a global problem, which seriously limits the clinical application of an LT. Premature LT aggravates the shortage of liver resources to a certain extent, and too much delay significantly increases the risk of complications and death. Therefore, this study reviews the current literature on LT in the treatment of ACLF and discusses further the challenges for ACLF patients, the timing of LT for ACLF, and the choice of the patient population.

Association of Plasma Fibrinogen Levels on Postoperative Day 1 with 2-Year Survival of Orthotopic Liver Transplantation for HBV-Related HCC

OBJECTIVE

To clarify the prognostic values of hemostatic parameters to predict the survival of patients undergoing orthotopic liver transplantation (OLT) for hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC).

METHODS

The data of 182 consecutive adult patients who underwent OLT for HBV-related HCC were subjected to univariate and multivariate analyses.

RESULTS

Ascites and fibrinogen levels on postoperative day (POD) 1 were independent predictors of postoperative 2-year mortality (both P <.05). Kaplan-Meier survival analysis showed that the higher the fibrinogen level on POD 1, the better the 1- and 2-year survival of patients with ascites (P <.05), whereas the fibrinogen level on POD 1 was associated with 1-year (P <.05) but not 2-year survival of patients without ascites.

CONCLUSION

Fibrinogen on POD 1 is a predictor of 2-year post-OLT survival of patients with HBV-related HCC with ascites.

Cost-effectiveness analysis of first-line treatment for chronic hepatitis B in China

OBJECTIVES

Hepatitis B virus infection is an important public health problem. We analysed the cost-effectiveness of the first-line therapies, including nucleotide analogues (namely tenofovir alafenamide fumarate (TAF), tenofovir disoproxil fumarate (TDF) and entecavir) and pegylated interferon (Peg-IFN) for patients with chronic hepatitis B (CHB) in China.

METHODS

A Markov model describing CHB disease progression was constructed to compare the cost-effectiveness of the first-line therapies, considering both satisfactory (HBeAg seroconversion) and optimal (HBsAg seroclearance) treatment goals. We examined the main outcomes, including cumulative lifetime cost per patient, incremental quality-adjusted life years (QALYs), incremental cost-effectiveness ratio and net monetary benefit. Uncertainty analysis was conducted to identify key influential parameters.

RESULTS

Compared with the baseline strategy, Peg-IFN had the highest QALY gain for HBeAg-positive (HBeAg+) CHB patients achieving a satisfactory goal and an optimal goal (3.19 and 6.32 respectively), and TDF was the most cost-effective therapy for HBeAg-negative CHB patients ($1418/QALY) achieving a satisfactory goal. Among nucleotide analogues, TAF was the most-effective strategy and had higher acceptability to achieve an optimal goal in the Eastern region of China (under 1 x GDP per capita threshold).

CONCLUSIONS

Among nucleotide analogues, TDF was the most cost-effective treatment in China for CHB patients to achieve satisfactory and optimal treatment goals, whereas TAF was cost-effective and more effective in the wealthier region. Peg-IFN was most cost-effective among HBeAg+ CHB patients to achieve both goals, with better clinical outcomes. Our findings also indicate the importance of regular monitoring during and after CHB treatment, and could inform treatment strategies in China and other countries.

Combining Donor and Recipient Age With Preoperative MELD and UKELD Scores for Predicting Survival After Liver Transplantation

OBJECTIVES

The end-stage liver disease scoring systems MELD, UKELD, and D-MELD (donor age × MELD) have had mediocre results for survival assessment after orthotopic liver transplant. Here, we introduced new indices based on preoperative MELD and UKELDscores and assessed their predictive ability on survival posttransplant.

MATERIALS AND METHODS

We included 1017 deceased donor orthotopic liver transplants that were performed between 2008 (the year UKELD was introduced) and 2019. Donor and recipient characteristics, liver disease scores, transplant characteristics, and outcomes were collected for analyses. D-MELD, D-UKELD (donor age × UKELD),DR-MELD[(donor age + recipient age) × MELD], and DR-UKELD [(donor age + recipient age) × UKELD] were calculated.

RESULTS

No score had predictive value for graft survival. For patient survival,DR-MELD and DR-UKELD provided the best results but with low accuracy. The highest accuracy was observed at 1 year posttransplant (areas under the curve of 0.598 [95% CI, 0.529-0.667] and 0.609 [95% CI, 0.549-0.67]forDR-MELDandDR-UKELD). Addition of donor and recipient age significantly improved the predictive abilities of MELD and UKELD for patient survival, but addition of donor age alone did not. For 1-year mortality (using receiver operating characteristic curves), optimal cut-off points were DR-MELD>2345 and DR-UKELD>5908. Recipients with DR-MELD >2345 (P < .001) and DR-UKELD >5908 (P = .002) had worse patient survival within the first year, but only DR-MELD >2345 remained significant after multivariable analysis (P = .007).

CONCLUSIONS

DR-MELD and DR-UKELD scores provided the best, albeit mediocre, predictive ability among the 6 tested models, especially at 1 year after posttransplant, although only for patient but not for graft survival. A DR-MELD >2345 was considered to be an additional independent risk factor for worse recipient survival within the first postoperative year.

Predictors of Mortality During Initial Liver Transplant Hospitalization and Investigation of Causes of Death

BACKGROUND Liver transplant (LT) remains a life-saving procedure with a high mortality rate. The present study investigated the causes of death and sought to identify predictive factors of mortality during the initial LT hospitalization. MATERIAL AND METHODS We retrieved data on first-time adult recipients who underwent LT between November 2017 and October 2019 receiving grafts from donation after citizen's death. The risk factors for mortality during the initial LT hospitalization were confirmed by univariate analysis. We also analyzed the causes of death. RESULTS We enrolled 103 recipients, including 86 males and 17 females, with a mean age of 47.7 years. Thirty-eight (36.9%) recipients were labeled as non-cholestatic cirrhosis-related indications. Approximately 8% of all recipients had diabetes prior to LT. Induction therapy was used in 11 (10.7%) recipients, along with maintenance therapy. The median model for end-stage liver disease score at LT was 32.4 (21.4-38.4). The in-hospital mortality rate of LT recipients was 6.8% (7/103), and infections were responsible for most of the deaths (6/7). The 1 remaining death resulted from primary graft failure. Univariate analysis showed recipients with postoperative pneumonia (p2 mg/dL, and alanine transaminase on day 1 after LT >1800 µmol/L (all P<0.001) were much more likely to die. CONCLUSIONS In-hospital mortality of LT recipients was high, due in large part to infections. Acute hepatic necrosis, prolonged post-transplant ICU stays, certain types of postoperative infections, and postoperative liver and kidney dysfunction were potential risk factors for in-hospital mortality of LT recipients.

Development of the Asian Transplant Registry Under the Asian Society of Transplantation

INTRODUCTION

In the Asian region, no international organ transplantation registry exists. Individual centers maintain their own database, or some countries developed a national registration system. To promote collaboration among Asian transplantation societies, the Asian Society of Transplantation (AST) has developed an international transplantation registry for the Asian countries that has been named as the Asian Society Transplant Registry (ASTREG).

METHODS

In 2017, the AST council formed a registry committee to develop 2 kinds of databases: ASTREG-N (nationwide level), which collects yearly aggregated data of participating countries, and ASTREG-H (hospital level), which collects the data of transplant recipients and donors from individual centers.

RESULTS

ASTREG-N collects each country's aggregate data of solid-organ transplantation, such as the total number of transplantations and deceased donors. ASTREG-H collects 5 transplant domains, namely recipient baseline characteristics, immunosuppression, post-transplant event, annual post-transplant evaluation, and donor traits. For the ASTREG-H project, South Korea, Philippines, Mongolia, and Myanmar are the current participants. A web-based secure data entry platform with real-time data visualization and automated data verification systems is currently available. Any participating centers can run this platform as their own data collection system.

CONCLUSION

The ASTREG is a collaborative project that will be the representative solid-organ transplantation database in the Asian region. It can aid in the harmonization of transplantation data in the Asian region.

Predicting Short-term Survival after Liver Transplantation using Machine Learning

Liver transplantation is one of the most effective treatments for end-stage liver disease, but the demand for livers is much higher than the available donor livers. Model for End-stage Liver Disease (MELD) score is a commonly used approach to prioritize patients, but previous studies have indicated that MELD score may fail to predict well for the postoperative patients. This work proposes to use data-driven approach to devise a predictive model to predict postoperative survival within 30 days based on patient’s preoperative physiological measurement values. We use random forest (RF) to select important features, including clinically used features and new features discovered from physiological measurement values. Moreover, we propose a new imputation method to deal with the problem of missing values and the results show that it outperforms the other alternatives. In the predictive model, we use patients’ blood test data within 1–9 days before surgery to construct the model to predict postoperative patients’ survival. The experimental results on a real data set indicate that RF outperforms the other alternatives. The experimental results on the temporal validation set show that our proposed model achieves area under the curve (AUC) of 0.771 and specificity of 0.815, showing superior discrimination power in predicting postoperative survival.

Neutrophilia is associated with a poorer clinical outcome in dogs with chronic hepatitis

BACKGROUND

Liver disease is a common cause of morbidity and mortality in dogs. Currently, it is challenging to prognosticate in these cases. The aim of this study was to evaluate the utility of the haematological variables in dogs with chronic hepatitis.

METHODS

Dogs with chronic hepatitis confirmed on histopathology had presenting haematological values retrospectively obtained and evaluated against survival time. Eighty-two dogs met the inclusion criteria and their data analysed.

RESULTS

Neutrophilic patients, with a count greater than 12×10⁹/l, controlled for sex and age, had a shorter survival time (P≤0.01). In dogs, neutrophilia at presentation predicted a poor outcome, whereas the other haematological parameters were not prognostically informative. When the dogs were split into even quarters on the basis of their neutrophil count, those within the higher quartiles had poorer survival times. Neutrophilia was associated with a poorer survival time in comparison to those patients with a lower count.

CONCLUSION

The relationship between neutrophils, inflammation and clinical outcome is deserving of future study in dogs with chronic hepatitis.

Pre-transplant ALBI Grade 3 Is Associated with Increased Mortality After Liver Transplantation

BACKGROUND

Although MELD score is a reliable tool for estimating mortality in the waiting list, criteria for preoperative prediction of survival after liver transplantation (LT) are lacking. ALBI score was validated as a prognostic marker for hepatocellular carcinoma patients undergoing transarterial chemoembolization, hepatic resection, and sorafenib treatment but not for LT outcomes yet. This study aimed to evaluate ALBI score as a prognostic factor in LT.

METHODS

This is a single-center analysis of patients undergoing LT between October 2001 and June 2017. Primary endpoint was overall post-LT mortality. Secondary endpoint was 90-day mortality.

RESULTS

Of all 301 patients included in this study, 185 (61.5%) were males. The median age was 54.1 ± 11.3 years. Univariate and multivariate analysis revealed that ALBI grade 3 (HR 1.836, 95% CI 1.154-2.921, p = 0.010), low serum albumin (HR 0.628, 95% CI 0.441-0.893, p = 0.010), black race (HR 2.431, 95% CI 1.160-5.092, p = 0.019), and elevated body mass index (HR 1.061, 95% CI 1.022-1.102, p = 0.002) all were associated with decreased overall survival following LT. Patients with both ALBI grade 3 (n = 25) and calculated MELD score ≥ 25 had the lowest overall survival (p < 0.001).

DISCUSSION

ALBI grade 3 was related to lower post-LT survival and can be utilized as a tool for risk stratification in LT.

New-onset hyperglycemia immediately after liver transplantation: A national survey from China Liver Transplant Registry

BACKGROUND

New-onset hyperglycemia (NOH) is a common phenomenon after liver transplantation (LT), but its impact on clinical outcomes has not yet been fully assessed. We aimed to evaluate the etiology and prognosis of NOH within 1 month after LT.

METHODS

The data of 3339 adult patients who underwent primary LT from donation after citizen death between January 2010 and June 2016 were extracted from China Liver Transplant Registry database and analyzed. NOH was defined as fasting blood glucose ≥7.0 mmol/L confirmed on at least two occasions within the first post-transplant month with or without hypoglycemic agent.

RESULTS

Of 3339 liver recipients, 1416 (42.4%) developed NOH. Recipients with NOH had higher incidence of post-transplant complications such as graft and kidney failure, infection, biliary stricture, cholangitis, and tumor recurrence in a glucose concentration-dependent manner as compared to non-NOH recipients (P < 0.05). The independent risk factors of NOH were donor warm ischemic time >10 min, cold ischemic time >10 h, anhepatic time >60 min, recipient model for end-stage liver disease score >30, moderate ascites and corticosteroid usage (P < 0.05). Liver enzymes (alanine aminotransferase and gamma-glutamyltranspeptidase) on post-transplant day 7 significantly correlated with NOH (P < 0.001).

CONCLUSIONS

NOH leads to increased morbidity and mortality in liver recipients. Close surveillance and tight control of blood glucose are desiderated immediately following LT particularly in those with delayed graft function and receiving corticosteroid. Strategic targeting graft ischemic injury may help maintain glucose homeostasis.

Value of the albumin-bilirubin score in the evaluation of hepatitis B virus-related acute-on-chronic liver failure, liver cirrhosis, and hepatocellular carcinoma

The aim of the present study was to investigate the value of the albumin-bilirubin (ALBI) score in the assessment of the disease conditions of hepatitis B virus (HBV)-related acute-on-chronic liver failure (HBV-ACLF), HBV-related liver cirrhosis (HBV-LC) and HBV-related hepatocellular carcinoma (HBV-HCC). A total of 395 patients with HBV-ACLF, HBV-LC, or HBV-HCC were retrospectively studied. The ALBI, Child-Turcotte-Pugh (CTP), and Model for End-Stage Liver Disease (MELD) scores of the patients were calculated, and the relationships between the ALBI score and the CTP and MELD scores were investigated. Furthermore, the ALBI grading was tested for the evaluation of the severity and stages of HBV-ACLF, HBV-LC, and HBV-HCC, especially when classifying the clinical stages of HBV-ACLF. The mean ALBI scores of the HBV-ACLF, HBV-LC, and HBV-HCC patients were -1.17±0.55, -1.76±0.66 and -2.59±0.62, respectively; the mean CTP scores were 10.70±1.81, 8.19±1.25 and 5.81±1.22, respectively; and the mean MELD scores were 19.93±7.44, 11.10±4.39 and 7.01±3.22, respectively. The ALBI scores were positively correlated with the CTP and MELD scores. The mean ALBI score and the frequency of grade 3 disease were higher in HBV-ACLF patients than in patients with HBV-LC or HBV-HCC. A later HBV-ACLF stage resulted in a higher frequency of ALBI grades of 3. In conclusion, ALBI scores exhibited parallel tendencies to the CTP and MELD scores in HBV-ACLF, HBV-LC, and HBV-HCC patients; thus, ALBI grading may be a simple but applicable method for the evaluation of the functional status of patients with HBV-related end-stage liver diseases.