Model of end stage liver disease (MELD) score greater than 23 predicts length of stay in the ICU but not mortality in liver transplant recipients

Impact of Blood Products Transfusion on Patients in the Immediate Post-Lung Transplant Period: A Cohort Study

BACKGROUND Anemia is common in post-transplant patients. Blood product transfusion is associated with mortality and rejection in solid organ transplants. In lung transplant recipients, transfusion predisposes to primary graft dysfunction (PGD). The adverse effects and associated mortality of perioperative transfusions in lung transplant recipients have not been evaluated. This study examined the effects of perioperative blood transfusions in lung transplant recipients. MATERIAL AND METHODS We conducted a retrospective study of the effects of blood product transfusions in patients who received single- or double-lung transplantation at Houston Methodist Hospital between August 2017 and September 2019. Univariable and multiple logistic regression modeling were used to determine the characteristics associated with single events as well as a composite outcome within 30 days (including mortality, acute myocardial infarction, acute stroke, lower respiratory tract infection, urinary tract infection, surgical site infections, or PGD). RESULTS A total of 232 patients received lung transplants between December 2015 and September 2019 at our center. Univariable analysis revealed an increased risk of PGD (P<0.001), more mechanical ventilation days (P<0.001), more ICU days post-transplant (P<0.001), and greater need for ECMO support (P=0.001) in patients who received blood product transfusions. In univariate analysis, the composite outcome was also more common (P=0.01) in patients who received any transfusion perioperatively. A total of 7 patients died within 30 days from transplant, and they were all in the transfused group. CONCLUSIONS Among lung transplant recipients, PGD, ICU days, need for mechanical ventilation and ECMO support, and total composite events were significantly greater in patients who received blood transfusion perioperatively.

Living-Donor Liver Transplantation for Hepatocellular Carcinoma: Impact of the MELD Score and Predictive Value of NLR on Survival

Background: Patients with hepatocellular carcinoma (HCC) tend to be referred for liver transplantation (LT) at an early stage of cirrhosis, with lower pre-LT Model of End-Stage Liver Disease (MELD) scores. We investigated the impact of high MELD scores on post-LT outcomes in patients with HCC and validated the prognostic significance of the neutrophil-to-lymphocyte ratio (NLR). Patients and Method: This retrospective single-center cohort study enrolled 230 patients with HCC who underwent LDLT from 2004−2019 in our institute. We defined a high MELD score as ≥20. Results: The MELD < 20 and MELD ≥ 20 groups comprised 205 and 25 cases, respectively. Although there was no significant difference in disease-free survival between the two groups (p = 0.629), the incidence of septic shock (p = 0.019) was significantly higher in the high MELD group. The one-, three-, and five-year overall survival rates were not significantly different between the two groups (p = 0.056). In univariate analysis, a high pre-LT NLR was associated with poorer survival in the high MELD group (p = 0.029, hazard ratio [HR]: 1.07, 90% confidence interval [CI]: 1.02−1.13). NLR cut-off values of ≥10.7 and <10.7 were predictive of mortality, with an AUC of 0.705 (90% CI: 0.532−0.879). The one-, three-, and five-year post-LT survival rates were significantly higher among the recipients with an NLR < 10.7 than those with an NLR ≥ 10.7 (p = 0.005). Conclusions: Pre-LT MELD score ≥ 20 was associated with a higher risk of developing post-LT septic shock and mortality. The pre-LT serum NLR is a useful predictive factor for clinical outcomes in patients with HCC with high MELD scores.

A simple CD4+ T cells to FIB-4 ratio for evaluating prognosis of BCLC-B hepatocellular carcinoma: a retrospective cohort study

Introduction

Immunotherapy has become a new therapy for advanced hepatocellular carcinoma (HCC); however, its treatment results are considerably different. CD4+ T cells (CD4+) are the key to immunotherapy, but patients with HCC that have low CD4+ are rarely observed for clinical evidence. Hepatitis B virus-related HCC is often accompanied by cirrhosis and portal hypertension; therefore, CD4+ tend to be relatively low in number. TACE is the standard treatment for Barcelona Clinic Liver Cancer (BCLC)-B HCC, which may further reduce the number of CD4 + .

Methods

This retrospective cohort study further reduced CD4+ by including patients with human immunodeficiency virus (HIV) to observe the relationship between CD4+ and Chronic hepatitis B virus (CHB) induced HCC. A total of 170 BCLC-B HCC patients (42 HIV+) were included. Univariate and multivariate analyses, and artificial neural networks (ANNs) were used to evaluate the independent risk factors for the two-year survival.

Results

The statistical analysis of the two-year survival rate showed that the main factors influencing survival were liver function and immune indices, including CD4+, platelet, alanine aminotransferase, aspartate aminotransferase, aspartate aminotransferase-to-platelet ratio index, and fibrosis-4 (FIB-4) (P < 0.05). Compared with that in other indices, in logistic and ANN multivariate analysis, CD4 + -to-FIB-4 ratio (CD4+/FIB-4) had the highest importance with 0.716 C-statistic and 145.93 cut-off value. In terms of overall survival rate, HIV infection was not a risk factor (P = 0.589); however, CD4+/FIB-4 ≤ 145.93 significantly affected patient prognosis (P = 0.002).

Conclusion

HIV infection does not affect the prognosis of BCLC-B HCC, but CD4+ have a significant predictive value. CD4+ played a vital role in HCC and this deserves the attention from physicians. Further, the CD4+/FIB-4 is a clinically valuable effective prognostic indicator for these patients.

Changes in the allocation policy for deceased donor livers in Korea: perspectives from anesthesiologists

Background

The allocation policy for deceased donor livers in Korea was changed in June 2016 from Child-Turcotte-Pugh (CTP) scoring system-based to Model for End-stage Liver Disease (MELD) scoring system-based. Thus, it is necessary to review the effect of allocation policy changes on anesthetic management.

Methods

Medical records of deceased donor liver transplantation (DDLT) from December 2014 to May 2017 were reviewed. We compared the perioperative parameters before and after the change in allocation policy.

Results

Thirty-seven patients underwent DDLT from December 2014 to May 2016 (CTP group), and 42 patients underwent DDLT from June 2016 to May 2017 (MELD group). The MELD score was significantly higher in the MELD group than in the CTP group (36.5 ± 4.6 vs. 26.5 ± 9.4, P < 0.001). The incidence of hepatorenal syndrome was higher in the MELD group than in the CTP group (26 vs. 7, P < 0.001). Packed red blood cell transfusion occurred more frequently in the MELD group than in the CTP group (5.0 ± 3.6 units vs. 3.4 ± 2.2 units, P = 0.025). However, intraoperative bleeding, vasopressor support, and postoperative outcomes were not different between the two groups.

Conclusions

Even though the patient’s objective condition deteriorated, perioperative parameters did not change significantly.

Defining postoperative transfusion thresholds in liver transplant recipients: A novel retrospective approach

BACKGROUND

The optimal transfusion threshold for most patient populations has been defined as hematocrit (HCT) <21%. However, some specific patient populations are known to benefit from higher transfusion thresholds. To date, the optimal postoperative transfusion threshold for patients undergoing liver transplant has not been determined. To define the ideal transfusion threshold for liver transplant patients, we designed a retrospective study of 496 liver transplant recipients.

METHODS

Using HCT prior to discharge as a surrogate marker for transfusion thresholds we grouped patients into three groups of transfusion thresholds (HCT <21%, <24%, and >30%). Transfusion rates (intra- and postoperative), graft and patient survival, and complications requiring readmission were compared between groups.

RESULTS

Ninety-two percent of patients were transfused during their hospital stay. Graft survival, patient survival, and rates of readmission within 30 days of discharge were no different between the three discharge HCT groups. Patients discharged with HCT >30% were less likely to be readmitted with infectious complications; however, this group also had the lowest model of end-stage liver (MELD) score at time of transplantation and were less likely to have received a transfusion during their hospital stay.

CONCLUSION

Transfusion thresholds of HCT <24%, and potentially as low as 21% are acceptable in postoperative liver transplant recipients. The conduct of a randomized clinical trial, as supported by these data, will be necessary to support the use of lower thresholds.

Delta MELD as a predictor of early outcome in adult-to-adult living donor liver transplantation

BACKGROUND/AIMS

An increased post-operative mortality risk has been reported among patients who undergo living donor liver transplantation (LDLT) with higher model for end-stage liver disease (MELD) scores. In this study, we investigated the effect of MELD score reduction on post-operative outcomes in patients with a high MELD (≥20) score by pre-transplant management.

MATERIALS AND METHODS

We retrospectively analyzed 386 LDLT cases, and patients were divided into low-MELD (<20, n=293) vs. high-MELD (≥20, n=93) groups according to their MELD score at the time of index hospitalization. Patients in the high-MELD group were managed specifically according to a treatment algorithm in an effort to decrease the MELD score. Patients in the high-MELD group were further divided into 2 subgroups: (1) responders (n=34) to pre-transplant treatment with subsequent reduction of the MELD score by a minimum of 1 point vs. (2) non-responders (n=59), whose MELD score remained unchanged or further increased on the day of LDLT. Responders vs. non-responders were compared according to etiology, demographics, and survival.

Outcomes of hemi- versus whole liver transplantation in patients from mainland china with high model for end-stage liver disease scores: a matched analysis

Background

Adult hemiliver transplantation (AHLT) is an important approach given the current shortage of donor livers. However, the suitability of AHLT versus adult whole liver transplantation (AWLT) for recipients with high Model for End-Stage Liver Disease (MELD) scores remains controversial.

Methods

We divided patients undergoing AHLT and AWLT into subgroups according to their MELD scores (≥ 30: AHLT, n = 35; AWLT, n = 88; and < 30: AHLT, n = 323; AWLT, n = 323). Patients were matched by demographic data and perioperative conditions according to propensity scores. A cut-off value of 30 for MELD scores was determined by comparing the overall survival data of 735 cases of nontumor liver transplantation.

Results

Among patients with an MELD score ≥ 30 and < 30, AHLT was found to be associated with increased warm ischemia time, operative time, hospitalization time, and intraoperative blood loss compared with AWLT (P < 0.05). In the MELD ≥ 30 group, although the 5-year survival rate was significantly higher for AWLT than for AHLT (P = 0.037), there was no significant difference between AWLT and AHLT in the MELD < 30 group (P = 0.832); however, we did not observe a significant increase in specific complications following AHLT among patients with a high MELD score (≥ 30). Among these patients, the incidence of complications classified as Clavien-Dindo grade III or above was significantly higher in patients undergoing AHLT than in those undergoing AWLT (25.7% vs. 11.4%, P = 0.047). For the MELD < 30 group, there was no significant difference in the incidence of complications classified as Clavien-Dindo grade III or above for patients undergoing AHLT or AWLT.

Conclusion

In patients with an MELD score < 30, AHLT can achieve rates of mortality and overall survival comparable to AWLT. In those with an MELD score ≥ 30, the prognosis and incidence of complications classified as Clavien-Dindo III or above are significantly worse for AHLT than for AWLT; therefore, we may need to be more cautious regarding the conclusion that patients with a high MELD score can safely undergo AHLT.

Impact of Integrating Insulin-Like Growth Factor 1 Levels into Model for End-Stage Liver Disease Score for Survival Prediction in Hepatocellular Carcinoma Patients

BACKGROUND

Liver reserve affects survival in hepatocellular carcinoma (HCC). Model for End-Stage Liver Disease (MELD) score is used to predict overall survival (OS) and to prioritize HCC patients on the transplantation waiting list, but more accurate models are needed. We hypothesized that integrating insulin-like growth factor 1 (IGF-1) levels into MELD score (MELD-IGF-1) improves OS prediction as compared to MELD.

METHODS

We measured plasma IGF-1 levels in training (n = 310) and validation (n = 155) HCC cohorts and created MELD-IGF-1 score. Cox models were used to determine the association of MELD and MELD-IGF-1 with OS. Harrell's c-index was used to compare the predictive capacity.

RESULTS

IGF-1 was significantly associated with OS in both cohorts. Patients with an IGF-1 level of ≤26 ng/mL in the training cohort and in the validation cohorts had significantly higher hazard ratios than patients with the same MELD but IGF-1 >26 ng/mL. In both cohorts, MELD-IGF-1 scores had higher c-indices (0.60 and 0.66) than MELD scores (0.58 and 0.60) (p < 0.001 in both cohorts). Overall, 26% of training and 52.9% of validation cohort patients were reclassified into different risk groups by MELD-IGF-1 (p < 0.001).

CONCLUSIONS

After independent validation, the MELD-IGF-1 could be used to risk-stratify patients in clinical trials and for priority assignment for patients on liver transplantation waiting list.

Protective Role of the Portocaval Shunt in Liver Transplantation

BACKGROUND

Advances in medical management and surgical technique have resulted in stepwise improvements in early post-transplant survival rates. Modifications in the surgical technique, such as the realization of the portocaval shunt (PCS), could influence survival rates. The aim of this study was to evaluate the mortality rate for 12 months after liver transplantation, analyzing the causes and risk factors related to its development and assessing the impact that PCS could have on them.

METHODS

A total of 231 recipients were included in the retrospective, longitudinal, and nonrandomized study.

RESULTS

The overall survival of the transplant was 85.2% (197 patients). The most frequent cause of death was infection (38.2%), followed by the multiorgan failure of multiple etiology (23.5%). Most of the risk factors related to mortality correspond to variables of the postoperative period. The results of the multivariate analysis identified the main risk factors for death: the presence of surgical complications and the need for renal replacement therapy. In contrast, the performance of PCS exerted a protective effect, reducing the probability of death by 70%.

CONCLUSIONS

Despite the good results obtained in several studies, there is still debate regarding the benefit of its realization. In our study, PCS was a factor associated with a reduction in mortality, with a markedly lower probability of adverse events. However, we agree with other authors on the need for larger and randomized studies to adequately determine the validity of such results.

Outcome of liver cirrhosis patients requiring prolonged mechanical ventilation

Acute respiratory failure requiring mechanical ventilation is a major indicator of intensive care unit (ICU) admissions in cirrhotic patients and is an independent risk factor for ICU mortality. This retrospective study aimed to investigate the outcome and mortality risk factors in patients with liver cirrhosis (LC) who required prolonged mechanical ventilation (PMV) between 2006 and 2013 from two databases: Taiwan’s National Health Insurance Research Database (NHIRD) and a hospital database. The hospital database yielded 58 LC patients (mean age: 65.3 years; men: 65.5%). The in-hospital mortality was significantly higher than in patients without LC. Based on the NHIRD database of PMV cases, patients were age-gender matched in a ratio of 1:2 for patients with and without LC. Model for End-Stage Liver Disease (MELD) score was calculated. The mortality was higher in patients with LC (19.5%) than those without LC (18.12%), though not statistically significant (p = 0.0622). Based on the hospital database, risk factor analysis revealed that patients who died had significant higher MELD score than the survivors (18.9 vs 13.7, p = 0.036) and patients with MELD score of >23 had higher risk of mortality than patients with MELD score of ≤23 (adjusted OR:9.26, 95% CI: 1.96–43.8). In conclusion, the in-hospital mortality of patients with high MELD scores who required PMV was high. MELD scores may be useful predictors of mortality in these patients.

Factors Associated With Length of Hospital Stay Following Liver Transplant Surgery

OBJECTIVES

Length of stay is considered an important surrogate for transplant survival rate and resource utilization. Therefore, in the present study, our aim was to determine factors affecting length of hospital stay.

MATERIALS AND METHODS

We retrospectively analyzed records of patients who underwent liver transplant at the Tehran University of Medical Sciences Liver Transplantation Center from March 2014 to March 2016.

RESULTS

For our final analyses, there were 161 adult recipients, including 106 males (65.8%) and 55 females (34.1%). Univariate analyses showed that body mass index, Modelfor End-Stage Liver Disease score, duration of surgery, number of administered packed red blood cells and fibrinogen during surgery, reoperation, retransplant, bacterial infection, pleural effusion, ascites, renal failure that required dialysis, and wound infection were risk factors for length of hospital stay. After multivariate linear regression analysis, only body mass index (β = 0.016; P = .028), Model for End-Stage Liver Disease score (β = 0.017; P = .002), surgical duration (β = 0.002; P = .001), reoperation (β = 0.016; P < .001), presence of pleural effusion (β = 0.212; P = .042), and management of bacterial infection (β = 0.21; P = .03) and psychiatric problems after liver transplant (β = 0.213; P = .025) were independent risk factors for length of hospital stay.

CONCLUSIONS

The present study showed that multiple preoperative, intraoperative, and postoperative variables could have an impact on length of hospitalization. Therefore, methods for assessing these factors could improve patient outcomes and resource savings in liver transplant centers.

Noncontrast Magnetic Resonance Angiography Clinical Application in Pre-Liver Transplant Recipients With Impaired Renal Function

Image evaluation of the vascular architecture is essential before living donor liver transplantation (LDLT). However, the use of contrast-enhanced study in recipients with impaired renal function is limited due to the risk of acute kidney injury and nephrogenic systemic fibrosis. Therefore, a contrast medium-free method is both valuable and necessary for preoperative vascular evaluation. Recent literature reported inflow-sensitive inversion recovery (IFIR) magnetic resonance angiography (MRA) without the use of a contrast medium to be a reproducible and noninvasive tool to assess hepatic vasculature with adequate-to-good image quality. The purpose of this study is to clinically apply IFIR MRA preoperatively in LDLT recipients. We retrospectively reviewed 31 LDLT recipients with renal function impairment from March 2013 to August 2018 who received IFIR MRA as a pretransplant vascular architecture evaluation and who underwent a subsequent LDLT. The image findings were assessed for subjective image quality and were compared with intraoperative findings. Our results showed that the pretransplant vascular anatomy was well correlated with intraoperative findings in all recipients. Successful ratings with image quality scores ≥2 for proper hepatic arteries (PHAs), portal veins, and inferior vena cavas (IVCs) were 100.0%, 96.8%, and 93.5%, respectively. Readable ratings with imaging quality score ≥1 for left and right hepatic arteries and gastroepiploic arteries were 83.9%, 96.7%, and 22.6%, respectively. We also found that recipients with higher Model for End-Stage Liver Disease scores (>23) had lower image quality scores for PHAs (P = 0.003) and IVCs (P = 0.046). However, images were still satisfactory for pre-liver transplantation (LT) vascular evaluation. In conclusion, in pre-LT recipients with impaired renal function, IFIR MRA is a feasible and reproducible image modality.

Variability in intensive care unit length of stay after liver transplant: Determinants and potential opportunities for improvement

PURPOSE

Recovery after liver transplant (LT) requires extensive resources, including prolonged intensive care unit stays. The objective of this study was to use an assessment tool to determine if LT recipients remain in ICU beyond designated indications.

METHODS

Records from 100 consecutive LTs performed in a single institution were retrospectively reviewed. An admission, discharge, and triage screening (ADT) tool was utilized to assess the indications for each ICU day. Data collected included demographics; pre-, intra-, and post-operative course; and complications. Days not meeting ADT criteria were considered additional ICU days.

RESULTS

100 patients: mean age 55 years (range 24-78 years) and mean MELD score 30 (range 6-47). Three recipients who died within one week were excluded. Forty-eight (49.5%) patients had a total of 75 additional days on initial ICU stay. Univariate analysis revealed no significant differences between patients with and without additional days. 12/97 (12.4%) patients returned to ICU including 5/48 and 7/49 with and without additional days.

CONCLUSION

Nearly half of the LT recipients remained in ICU an average of 1.6 additional days. Monitoring of organ function appeared to be the most common reason. Opportunities to improve resource utilization could include transfer to an intermediate/progressive care ("step-down") unit.

Impact of early reoperation on graft survival after liver transplantation: Univariate and multivariate analysis

BACKGROUND

Data on rate, risk factors, and consequences of early reoperation after liver transplantation are still limited.

STUDY DESIGN

Single-center retrospective analysis of data of 428 patients, who underwent liver transplantation in period between January 2009 and December 2014. Univariate and multivariate analysis were used to study the risk factors of early reoperation and its impact on graft survival.

RESULTS

Of 428 patients, 74 (17.3%) underwent early reoperation. Of them, 46 (62.2%) underwent reoperation within the first week and 28 (37.8%) underwent reoperation later than 1 week after transplantation. With multivariate analysis, significant risk factors of early reoperation included pretransplant ICU admission, previous abdominal surgery and diabetes. Early reoperation itself was not found to be an independent predictor of graft loss. However, early reoperation later than 7 days from transplant was found to be independent predictor of graft loss (odds ratio [OR] = 5.125; 95% CI, 1.358-19.552; P = .016). In our series, other independent predictors of graft loss were MELD score (P = .010) and operative time (P = .048).

CONCLUSIONS

This analysis demonstrates that early reoperations later than a week appear to negatively impact the graft survival. The timing of early reoperation should be a focus of additional studies.

Postoperative Meld-Lactate and Isolated Lactate Values As Outcome Predictors Following Orthotopic Liver Transplantation

The Model for End Stage Liver (MELD) score is validated to predict pretransplant mortality. However, as a predictor of postoperative outcomes, its utility has proven inconsistent. Recently developed MELD-Lactate models better predict 30-day survival as compared with the MELD and MELD-Sodium scores. We compared the MELD-Lactate, original MELD, and MELD-Sodium formulae and the initial postoperative lactate as predictors of 30-day and in-hospital mortality following liver transplantation.Adult patients (n = 989) undergoing orthotopic liver transplant between 2002 to 2013 were included. In addition to the previous models, the first postoperative lactate value and a newly derived Mount Sinai MELD-Lactate score and associated c-statistics were compared.The Mount Sinai MELD-Lactate model yielded the highest c-statistic value (0.749), followed by the original MELD-Lactate (0.740), initial lactate value (0.729), postoperative MELD (0.653), and MELD-Sodium (0.641) models in predicting survival at 30 days following liver transplantation. For in-hospital mortality, the original MELD-Lactate model had slightly higher c-statistic (0.739) compared with the Mount Sinai MELD-Lactate model (0.734). Despite the distribution differences in the MELD-Lactate models, the model validation results, both from cross-validation and bootstrap methods, were similar.Postoperative MELD-Lactate and isolated postoperative lactate values were moderately predictive of 30-day and in-hospital mortality following liver transplantation in this patient cohort.

Risk Factors of Prolonged ICU Stay in Liver Transplant Recipients in a Single-Center Experience

BACKGROUND

Prolonged initial intensive care unit (ICU) stay after liver transplantation (LT) is associated with prolonged total hospitalization, increased hospital mortality, and impaired patient and graft survival. Recent data suggested that model for end-stage liver disease (MELD) score at the time of LT and the length of surgery were the two independent risk factors for an ICU stay longer than 3 days after LT. We further identified factors influencing prolonged ICU stay in single-center liver graft recipients.

PATIENTS AND METHODS

One hundred fifty consecutive LT recipients (M/F 94/56, median age 55 (range, 39-60), 36% with viral hepatitis, were prospectively enrolled into the study. Associations between clinical factors and prolonged ICU stay were evaluated using logistic regression models. Receiver operating characteristic curves were analyzed to determine the appropriate cutoffs for continuous variables. Threshold for significance was P ≤ .05.

RESULTS

Highly prolonged (≥8 days) and moderately prolonged (≥6 days) postoperative ICU stay was noted in 19 (12.7%) and 59 (39.3%) patients, respectively. Serum bilirubin (P = .001) and creatinine concentrations (P = .011), international normalized ratio (P = .004), and sodium-MELD (P < .001) were all significantly associated with postoperative intensive care unit stay over or equal to 75th percentile (6 days). Sodium-MELD was significantly associated with postoperative care unit stay greater or equal to the 90th percentile (8 days; P = .018).

CONCLUSIONS

Sodium-MELD might be a novel risk factor of prolonged ICU stay in this single-center experience.

MELD score as a predictor of mortality, length of hospital stay, and disease burden: A single-center retrospective study in 39,323 inpatients

The laboratory-based model for end-stage liver disease (MELD) score reflects the function of the kidney, liver, and extrinsic coagulation pathway and might be used as a general prognostic tool for the assessment of patients. We therefore aimed to investigate a potential association of the MELD score with mortality, length of hospital stay (LOS), and disease burden in a general patient population.We performed a retrospective observational study at a tertiary referral center. From January 2012 through December 2013, all consecutive inpatients aged 18 years were eligible for the study; patients with missing MELD parameters on hospital admission and/or treatments influencing the international normalized ratio, that is, novel oral anticoagulants and vitamin K antagonists, were excluded. The MELD score on hospital admission was calculated retrospectively. The primary outcome measure was in-hospital all-cause mortality; secondary outcome measures were LOS and the number of comorbidities.A total of 39,323 inpatients were included in the final analysis. On admission, MELD scores of 15 to 19, 20 to 29, and ≥30 points (reference <15 points) showed increased hazard ratios (HRs) for in-hospital mortality in uni- and multivariable analysis with an adjusted HR of 2.52 (95% confidence interval [CI], 1.81-3.49; P < .001), 2.70 (95% CI, 1.89-3.84; P < .001), and 8.00 (95% CI, 3.91-16.39; P < .001), respectively. Increased MELD scores of 15 to 19, 20 to 29, and ≥30 points were positively associated with LOS and the number of comorbidities in uni- and multivariable analysis.In our study population consisting of adult inpatients, the MELD score on hospital admission was significantly associated with mortality, LOS, and the number of comorbidities. We suggest to prospectively validate the MELD score in inpatients as part of clinical decision support systems.

High MELD score and extended operating time predict prolonged initial ICU stay after liver transplantation and influence the outcome

BACKGROUND

The aim of the present study is to determine the incidence of a prolonged (>3 days) initial ICU-stay after liver transplantation (LT) and to identify risk factors for it.

PATIENTS AND METHODS

We retrospectively analyzed data of adult recipients who underwent deceased donor first-LT at the University Hospital Essen between 11/2003 and 07/2012 and showed a primary graft function.

RESULTS

Of the 374 recipients, 225 (60.16%) had prolonged ICU-stay. On univariate analysis, donor INR, high doses of vasopressors, "rescue-offer" grafts, being hospitalized at transplant, high urgency cases, labMELD, alcoholic cirrhosis, being on renal dialysis and length of surgery were associated with prolonged ICU-stay. After multivariate analysis, only the labMELD and the operation's length were independently correlated with prolonged ICU-stay. Cut-off values for these variables were 19 and 293.5 min, respectively. Hospital stay was longer for patients with a prolonged initial ICU-stay (p<0.001). Survival rates differed significantly between the two groups at 3 months, 1-year and 5-years after LT (p<0.001).

CONCLUSIONS

LabMELD and duration of LT were identified as independent predictors for prolonged ICU-stay after LT. Identification of recipients in need of longer ICU-stay could contribute to a more evidenced-based and cost-effective use of ICU facilities in transplant centers.

Liver transplantation after share 35: Impact on pretransplant and posttransplant costs and mortality

Share 35 was implemented in 2013 to direct livers to the most urgent candidates by prioritizing Model for End-Stage Liver Disease (MELD) ≥ 35 patients. We aim to evaluate this policy's impact on costs and mortality. Our study includes 834 wait-listed patients and 338 patients who received deceased donor, solitary liver transplants at Mayo Clinic between January 2010 and December 2014. Of these patients, 101 (30%) underwent transplantation after Share 35. After Share 35, 29 (28.7%) MELD ≥ 35 patients received transplants, as opposed to 46 (19.4%) in the pre-Share 35 era (P = 0.06). No significant difference in 90-day wait-list mortality (P = 0.29) nor 365-day posttransplant mortality (P = 0.68) was found between patients transplanted before or after Share 35. Mean costs were $3,049 (P = 0.30), $5226 (P = 0.18), and $10,826 (P = 0.03) lower post-Share 35 for the 30-, 90-, and 365-day pretransplant periods, and mean costs were $5010 (P = 0.41) and $5859 (P = 0.57) higher, and $9145 (P = 0.54) lower post-Share 35 for the 30-, 90-, and 365-day posttransplant periods. In conclusion, the added cost of transplanting more MELD ≥ 35 patients may be offset by pretransplant care cost reduction. Despite shifting organs to critically ill patients, Share 35 has not impacted mortality significantly. Liver Transplantation 23:11-18 2017 AASLD.

TLR4/CD14 Variants-Related Serologic and Immunologic Dys-Regulations Predict Severe Sepsis in Febrile De-Compensated Cirrhotic Patients

Genetic variants and dysfunctional monocyte had been reported to be associated with infection susceptibility in advanced cirrhotic patients. This study aims to explore genetic predictive markers and relevant immune dysfunction that contributed to severe sepsis in febrile acute de-compensated cirrhotic patents. Polymorphism analysis of candidate genes was undergone in 108 febrile acute de-compensated cirrhotic patients and 121 healthy volunteers. Various plasma inflammatory/regulatory cytokines, proportion of classical (CD 16-, phagocytic) and non-classical (CD16+, inflammatory) monocytes, lipopolysaccharide (LPS)-stimulated toll-like receptor 4 (TLR4) and intracellular/extracellular cytokines on cultured non-classical monocytes, mCD14/HLA-DR expression and phagocytosis of classical monocytes were measured. For TLR4+896A/G variant allele carriers with severe sepsis, high plasma endotoxin/IL-10 inhibits HLA-DR expression and impaired phagocytosis were noted in their classical monocyte. In the same group, increased non-classical monocyte subset, enhanced LPS-stimulated TLR4 expression and TNFα/nitrite production, and systemic inflammation [high plasma soluble CD14 (sCD14) and total nitric oxide (NOx) levels] were noted. For CD14-159C/T variant allele carriers with severe sepsis, persist endotoxemia inhibited mCD14/HLA-DR expression and impaired phagocytosis of their classical monocyte. In the same group, increased non-classical monocyte subset up-regulated TLR4-NFκB-iNOS and p38MAPK pathway, stimulated TNFα/nitrite production and elicited systemic inflammation. In febrile acute de-compensated cirrhotic patients, TLR4+896A/G and CD14-159C/T polymorphisms-related non-classical and classical monocytes dysfunction resulted in increased severe sepsis risk. Malnutrition, high plasma endotoxin and sCD14 levels, single TLR4+896A/G or CD14-159C/T variant allele carriers and double variant allele carriers are significant predictive factors for the development of severe sepsis among them.

Pretransplant Factors and Associations with Postoperative Respiratory Failure, ICU Length of Stay, and Short-Term Survival after Liver Transplantation in a High MELD Population

Changes in distribution policies have increased median MELD at transplant with recipients requiring increasing intensive care perioperatively. We aimed to evaluate association of preoperative variables with postoperative respiratory failure (PRF)/increased intensive care unit length of stay (ICU LOS)/short-term survival in a high MELD cohort undergoing liver transplant (LT). Retrospective analysis identified cases of PRF and increased ICU LOS with recipient, donor, and surgical variables examined. Variables were entered into regression with end points of PRF and ICU LOS > 3 days. 164 recipients were examined: 41 (25.0%) experienced PRF and 74 (45.1%) prolonged ICU LOS. Significant predictors of PRF with univariate analysis: BMI > 30, pretransplant MELD, preoperative respiratory failure, LVEF < 50%, FVC < 80%, intraoperative transfusion > 6 units, warm ischemic time > 4 minutes, and cold ischemic time > 240 minutes. On multivariate analysis, only pretransplant MELD predicted PRF (OR 1.14, p = 0.01). Significant predictors of prolonged ICU LOS with univariate analysis are as follows: pretransplant MELD, FVC < 80%, FEV1 < 80%, deceased donor, and cold ischemic time > 240 minutes. On multivariate analysis, only pretransplant MELD predicted prolonged ICU LOS (OR 1.28, p < 0.001). One-year survival among cohorts with PRF and increased ICU LOS was similar to subjects without. Pretransplant MELD is a robust predictor of PRF and ICU LOS. Higher MELDs at LT are expected to increase need for ICU utilization and modify expectations for recovery in the immediate postoperative period.

Is MELD score failing patients with liver disease and hepatorenal syndrome?

There is a need to reassess the application of MELD and the impact of renal insufficiency with consideration for developing an algorithm with exception points that would lead to timely allocation of livers to patients with hepatorenal syndrome prior to occurrence of permanent renal damage without jeopardizing post-transplant survival.

LIPID PROFILE OF CIRRHOTIC PATIENTS AND ITS ASSOCIATION WITH PROGNOSTIC SCORES: a cross-sectional study

BACKGROUND

In cirrhosis the production of cholesterol and lipoproteins is altered.

OBJECTIVE

Evaluate the lipid profile by measuring total cholesterol, very low-density lipoprotein, low-density lipoprotein, high-density lipoprotein and triglyceride levels in patients with cirrhosis caused by alcoholism and/or hepatitis C virus infection and determine its association with Child-Pugh and MELD scores.

METHODS

Cross-sectional retrospective study of patients treated at the outpatient clinic in Porto Alegre, Brazil, from 2006 to 2010.

RESULTS

In total, 314 records were reviewed, and 153 (48.7%) met the inclusion criteria, of which 82 (53.6%) had cirrhosis that was due to hepatitis C virus infection, 50 (32.7%) were due to alcoholism, and 21 (13.7%) were due to alcoholism and hepatitis C virus infection. The total cholesterol levels diminished with a Child-Pugh progression (P<0.001). Child-Pugh C was significantly associated with lover levels of low-density lipoprotein (<70 mg/dL; P<0.001), high-density lipoprotein (<40 mg/dL; P<0.001) and triglyceride (<70 mg/dL; P=0.003). MELD>20 was associated with lower total cholesterol levels (<100mg/dL; P<0.001), very low-density lipoprotein (<16 mg/dL; P=0.006), and low-density lipoprotein (<70 mg/dL; P=0.003). Inverse and statistically significant correlations were observed between Child-Pugh and all the lipid fractions analyzed (P<0.001). The increase in MELD was inversely correlated with reduced levels in total cholesterol (P<0.001), high-density lipoprotein (P<0.001), low-density lipoprotein (P<0.001), very low-density lipoprotein (P=0.030) and triglyceride (P=0.003).

CONCLUSION

A reduction in the lipid profile in patients with cirrhosis due to hepatitis C virus infection and/or alcoholism was significantly associated with the Child-Pugh and MELD prognostic markers. These results suggest that the lipid profile may be used as a tool to assist in evaluating liver disease.

Elevation of HO-1 Expression Mitigates Intestinal Ischemia-Reperfusion Injury and Restores Tight Junction Function in a Rat Liver Transplantation Model

Aims. This study was aimed at investigating whether elevation of heme oxygenase-1 (HO-1) expression could lead to restoring intestinal tight junction (TJ) function in a rat liver transplantation model. Methods. Intestinal mucosa injury was induced by orthotopic autologous liver transplantation (OALT) on male Sprague-Dawley rats. Hemin (a potent HO-1 activator) and zinc-protoporphyrin (ZnPP, a HO-1 competitive inhibitor), were separately administered in selected groups before OALT. The serum and intestinal mucosa samples were collected at 8 hours after the operation for analysis. Results. Hemin pretreatment significantly reduced the inflammation and oxidative stress in the mucosal tissue after OALT by elevating HO-1 protein expression, while ZnPP pretreatment aggravated the OALT mucosa injury. Meanwhile, the restriction on the expression of tight junction proteins zonula occludens-1 and occludin was removed after hemin pretreatment. These molecular events led to significant improvement on intestinal barrier function, which was proved to be through increasing nuclear translocation of nuclear factor-E2-related factor 2 (Nrf2) and reducing nuclear translocation of nuclear factor kappa-B (NF-κB) in intestinal injured mucosa. Summary. Our study demonstrated that elevation of HO-1 expression reduced the OALT-induced intestinal mucosa injury and TJ dysfunction. The HO-1 protective function was likely mediated through its effects of anti-inflammation and antioxidative stress.

Postoperative resource utilization and survival among liver transplant recipients with Model for End-stage Liver Disease score ≥ 40: A retrospective cohort study

BACKGROUND

Cirrhotic patients with Model for End-stage Liver Disease (MELD) score ≥ 40 have high risk for death without liver transplant (LT).

OBJECTIVE

To evaluate these patients' outcomes after LT.

METHODS

The present study analyzed a retrospective cohort of 519 cirrhotic adult patients who underwent LT at a single Canadian centre between 2002 and 2012. Primary exposure was severity of liver disease measured by MELD score at LT (≥ 40 versus < 40). Primary outcome was duration of first intensive care unit (ICU) stay after LT. Secondary outcomes were duration of first hospital stay after LT, rate of ICU readmission, re-LT and survival rates.

RESULTS

On the day of LT, 5% (28 of 519) of patients had a MELD score ≥ 40. These patients had longer first ICU stays after LT (14 versus two days; P < 0.001). MELD score ≥ 40 at LT was independently associated with first ICU stay after LT ≥ 10 days (OR 3.21). These patients had longer first hospital stays after LT (45 versus 18 days; P < 0.001); however, there was no significant difference in the rate of ICU readmission (18% versus 22%; P = 0.58) or re-LT rate (4% versus 4%; P = 1.00). Cumulative survival at one month, three months, one year, three years and five years was 98%, 96%, 90%, 79% and 72%, respectively. There was no significant difference in cumulative survival stratified according to MELD score ≥ 40 versus < 40 at LT (P = 0.59).

CONCLUSIONS

Cirrhotic patients with MELD score ≥ 40 at LT utilize greater postoperative health resources; however, they derive similar long-term survival benefit from LT.

Hepatosplanchnic circulation in cirrhosis and sepsis

Hepatosplanchnic circulation receives almost half of cardiac output and is essential to physiologic homeostasis. Liver cirrhosis is estimated to affect up to 1% of populations worldwide, including 1.5% to 3.3% of intensive care unit patients. Cirrhosis leads to hepatosplanchnic circulatory abnormalities and end-organ damage. Sepsis and cirrhosis result in similar circulatory changes and resultant multi-organ dysfunction. This review provides an overview of the hepatosplanchnic circulation in the healthy state and in cirrhosis, examines the signaling pathways that may play a role in the physiology of cirrhosis, discusses the physiology common to cirrhosis and sepsis, and reviews important issues in management.

Advances in management and prognostication in critically ill cirrhotic patients

PURPOSE OF REVIEW

To provide an update on the recent publications for the management and prognostication of critically ill cirrhotic patients before and after liver transplant.

RECENT FINDINGS

The CLIF Acute-oN-ChrONicLIver Failure in Cirrhosis (CANONIC) study recently derived an evidence-based definition of acute-on-chronic liver failure (ACLF): hepatic decompensation; organ failure [predefined by the Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA)]; and high 28-day mortality rate. Although Sequential Organ Failure Assessment (SOFA) appears to be more accurate in predicting ICU and hospital mortality in ACLF patients, CLIF-SOFA has been derived specifically for critically ill cirrhotic patients, including those not receiving mechanical ventilation. Recent data suggest that a lower transfusion target in esophageal variceal bleeding (<7 g/l) is safe. Newly defined 'cirrhosis-associated acute kidney injury (AKI)' correlates with mortality, organ failure and length of hospital stay. Although the SOFA score appears to perform better than liver-specific scoring systems [Model for End-stage Liver Disease (MELD) and Child-Pugh scores], neither MELD nor SOFA appears to independently predict posttransplant survival; however, correlated with lengths of ICU and hospital stay. For patients declined for liver transplant, palliative care referral and appropriate goals of care are rarely achieved.

SUMMARY

New definitions for ACLF, cirrhosis-associated AKI and the CLIF-SOFA may improve the discrimination between survivors and nonsurvivors with ACLF. Predicting futility postliver transplant based on preliver transplant severity of illness still poses significant challenges.

The combination of MELD score and ICG liver testing predicts length of stay in the ICU and hospital mortality in liver transplant recipients

BACKGROUND

Early prediction of outcome would be useful for an optimal intensive care management of liver transplant recipients. Indocyanine green clearance can be measured non-invasively by pulse spectrophometry and is closely related to liver function.

METHODS

This study was undertaken to assess the predictive value of a combination of the model of end stage liver disease (MELD) score and early indocyanine plasma disappearance rates (ICG-PDR) for length of stay in the intensive care unit (ICU), length of stay in the hospital and hospital mortality in liver transplant recipients.

RESULTS

Fifty consecutive liver transplant recipients were included in this post Hoc single-center study. ICG-PDR was determined within 6 hours after ICU admission. Endpoints were length of stay in the ICU, length of hospital stay and hospital mortality. The combination of a high MELD score (MELD >25) and a low ICG-PDR clearance (ICG-PDR < 20%/minute) predicts a significant longer stay in the ICU (p = 0.004), a significant longer stay in the hospital (p < 0.001) and a hospital mortality of 40% vs. 0% (p = 0.003).

CONCLUSION

The combination of MELD scores and a singular ICG-PDR measurement in the early postoperative phase is an accurate predictor for outcome in liver transplant recipients. This easy-to-assess tool might be valuable for an optimal intensive care management of those patients.

Influence on ICU course, outcome and costs for lung transplantation after implementation of the new Swiss transplantation law

BACKGROUND

The Swiss organ allocation system for donor lungs was implemented on 1 July 2007. The effects of this implementation on patient selection, intensive care unit course, outcomes and intensive care costs are unknown.

METHODS

The first 37 consecutive lung transplant recipients following the implementation of the new act were compared with the previous 42 lung transplant recipients.

RESULTS

Following implementation of the new law, baseline characteristics and cumulative one-year patient survival were comparable in both groups (88.1% vs 83.8%, P = 0.58). The costs for each case increased by 35,000 euros after adoption of the new law. Stratifying patients after implementation of the law according to urgency status shows that urgent patients required longer mechanical ventilation (P = 0.04), a longer ICU stay (P = 0.045) and a longer hospital stay (P = 0.04) and ICU costs (median 64,050 euros) were higher compared to regular patients.

CONCLUSION

The new transplantation law has increased ICU costs with the implementation of the Swiss organ allocation system. Patients listed as 'urgent' contribute significantly to the increase in ICU costs.

Effect of preoperative iron deficiency in liver transplant recipients on length of intensive care unit stay

Liver transplant (LT) recipients often display iron deficiency preoperatively, which significantly increases the quantity of blood that needs to be transfused intraoperatively, A risk factor for a prolonged intensive care unit (ICU) stay. The aim of this retrospective study was to determine whether there was a clinically significant association between iron deficiency and the length of ICU stay, among 153 patients scheduled for OLT from September 2011 to June 2012. Patients were divided into 2 groups according to their baseline iron status: iron- deficient (ID) and non-ID (normal iron profile) cohorts. Iron deficiency was assessed on the basis of several parameters; transferrin saturation as well as serum iron, ferritin, soluble transferrin receptor, and C-reactive protein levels. We retrospectively analyzed the data regarding demographic and clinical features, preoperative laboratory values, intraoperative transfusions, and length of ICU stay. Patient demographic features and preoperative values were similar between the groups. Preoperative iron deficiency, which was diagnosed in 72 patients (58.6%), was associated with a greater intraoperative use of fresh frozen plasma and red blood cell transfusions (P = .0001). The median length of ICU stay after LT was longer among the ID versus the non-ID group (5 and 3 days per patient, respectively; P = .0001). Therefore, we have suggested that preoperative iron deficiency may be a prognostic factor for the length of ICU stay after LT.

Association of intraoperative transfusion of blood products with mortality in lung transplant recipients

BACKGROUND

The impact of intraoperative transfusion on postoperative mortality in lung transplant recipients is still elusive.

METHODS

Univariate and multivariate analysis were performed to investigate the influence of red blood cells (RBCs) and fresh frozen plasma (FFP) on mortality in 134 consecutive lung transplants recipients from September 2003 until December 2008.

RESULTS

Intraoperative transfusion of RBCs and FFP was associated with a significant increase in mortality with odds ratios (ORs) of 1.10 (1.03 to 1.16, P = 0.02) and 1.09 (1.02 to 1.15, P = 0.03), respectively. For more than four intraoperatively transfused RBCs multivariate analysis showed a hazard ratio for mortality of 3.8 (1.40 to 10.31, P = 0.003). Furthermore, non-survivors showed a significant increase in renal replacement therapy (RRT) (36.6% versus 6.9%, P <0.0001), primary graft dysfunction (PGD) (39.3% versus 5.9%, P <0.0001), postoperative need of extracorporeal membrane oxygenation (ECMO) (26.9% versus 3.1%, P = 0.0019), sepsis (24.2% versus 4.0%, P = 0.0004), multiple organ dysfunction syndrome (MODS) (26.9% versus 3.1%, P <0.0001), infections (18.1% versus 0.9%, P = 0.0004), retransplantation (12.1% versus 6.9%, P = 0.039) and readmission to the ICU (33.3% versus 12.8%, P = 0.024).

CONCLUSIONS

Intraoperative transfusion is associated with a strong negative influence on outcome in lung transplant recipients.

Introducing an optimal liver allocation system for liver cirrhosis patients

BACKGROUND

Liver transplantation (LT) is the only treatment option for patients with advanced liver disease. Currently, liver donation to these patients, considering priorities, is based on the Model for End-Stage Liver Disease (MELD). MELD score is a tool for predicting the risk of mortality in patients with advanced liver disease. However, few studies have so far been conducted in Iran on the efficacy of MELD score of these patients.

OBJECTIVES

This study reviews the present status of the MELD score and introduces a new model for optimal prediction of the risk of mortality in Iranian patients with advanced liver disease.

PATIENTS AND METHODS

Data required were collected from 305 patients with advanced liver disease who enrolled in a waiting list (WL) in Imam Khomeini Hospital from May 2008 to May 2009. All of the patients were followed up for at least 3 years until they died or underwent LT. Cox regression analysis was applied to select the factors affecting their mortality. Survival curves were plotted. Wilcoxson test and receiver operating characteristics curves for survival predictive model were used to compare the scores. All calculations were performed with the SPSS (version 13.0) and R softwares.

RESULTS

During the study, 71 (23.3%) patients died due to liver cirrhosis and 43 (14.1%) underwent LT. Viral Hepatitis (43.7%) is the most common cause of end-stage liver disease among Iranian patients. A new model (NMELD) was proposed with the use of the natural logarithms of two blood serum variables (total bilirubin and albumin) and the patients' age (year) by applying the Cox model: NMELD = 10 × (0.736 × ln (bilirubin) - 1.312 × ln (albumin) + 0.025 × age + 1.776).

CONCLUSIONS

The results of the Wilcoxon test showed that there is a significant difference between the usual MELD and our proposed NMELD scores (P < 0.001). Receiver operating characteristics curve for survival predictive model indicated that the NMELD score is more efficient compared with the MELD score in predicting the risk of mortality. Since serum creatinine was not significant in NMELD score, further studies to clarify this issue are suggested.

Extracorporeal detoxification for hepatic failure using molecular adsorbent recirculating system: depurative efficiency and clinical results in a long-term follow-up

Acute liver failure and acute-on-chronic liver failure still show a poor prognosis. The molecular adsorbent recirculating system (MARS) has been extensively used as the most promising detoxifying therapy for patients with these conditions. Sixty-four patients with life-threatening liver failure were selected, and 269 MARS treatments were carried out as a bridge for orthotopic liver transplantation (OLT) or for liver function recovery. All patients were grouped according to the aim of MARS therapy. Group A consisted of 47 patients treated for liver function recovery (median age 59 years, range 23-82). Group B consisted of 11 patients on the waiting list who underwent OLT (median age 47 years, range 32-62). Group C consisted of 6 patients on the waiting list who did not undergo OLT (median age 45.5 years, range 36-54, P = 0.001). MARS depurative efficiency in terms of liver toxins, cytokines, and growth factors was assessed together with the clinical outcome of the patients during a 1-year follow-up. Total bilirubin reduction rate per session (RRs) for each MARS session was 23% (range 17-29); direct bilirubin RRs was 28% (21-35), and indirect bilirubin RRs was 8% (3-21). Ammonia RRs was 34% (12-86). Conjugated cholic acid RRs was 58% (48-61); chenodeoxycholic acid RRs was 34% (18-48). No differences were found between groups. Hepatocyte growth factor (HGF) values on starting MARS were 4.1 ng/mL (1.9-7.9) versus 7.9 ng/mL (3.2-14.1) at MARS end (P < 0.01). Cox regression analysis to determine the risk factors predicting patient outcomes showed that age, male gender, and Sequential Organ Failure Assessment score (but not Model for End-stage Liver Disease score) were factors predicting death, whereas the number of MARS sessions and the ΔHGF proved protective factors. Kaplan-Meier survival analysis was also used; after 12 months, 21.3% of patients in Group A survived, while 90.9% were alive in Group B and 16.7% in Group C (log rank = 0.002). In conclusion, MARS was clinically well tolerated by all patients and significantly reduced hepatic toxins. Better survival rates were linked to an OLT program, but patients' clinical characteristics on starting MARS therapy were the main factors predicting survival. The role of HGF should be evaluated in larger clinical trials.

Survival outcomes of right-lobe living donor liver transplantation for patients with high Model for End-stage Liver Disease scores

BACKGROUND

Controversy exists over whether living donor liver transplantation (LDLT) should be offered to patients with high Model for End-stage Liver Disease (MELD) scores. This study tried to determine whether a high MELD score would result in inferior outcomes of right-lobe LDLT.

METHODS

Among 411 consecutive patients who received right-lobe LDLT at our center, 143 were included in this study. The patients were divided into two groups according to their MELD scores: a high-score group (MELD score ≥25; n=75) and a low-score group (MELD score <25; n=68). Their demographic data and perioperative conditions were compared. Univariable and multivariable analyses were performed to identify risk factors affecting patient survival.

RESULTS

In the high-score group, more patients required preoperative intensive care unit admission (49.3% vs 2.9%; P<0.001), mechanical ventilation (21.3% vs 0%; P<0.001), or hemodialysis (13.3% vs 0%; P=0.005); the waiting time before LDLT was shorter (4 vs 66 days; P<0.001); more blood was transfused during operation (7 vs 2 units; P<0.001); patients stayed longer in the intensive care unit (6 vs 3 days; P<0.001) and hospital (21 vs 15 days; P=0.015) after transplantation; more patients developed early postoperative complications (69.3% vs 50.0%; P=0.018); and values of postoperative peak blood parameters were higher. However, the two groups had comparable hospital mortality. Graft survival and patient overall survival at one year (94.7% vs 95.6%; 95.9% vs 96.9%), three years (91.9% vs 92.6%; 93.2% vs 95.3%), and five years (90.2% vs 90.2%; 93.2% vs 95.3%) were also similar between the groups.

CONCLUSIONS

Although the high-score group had significantly more early postoperative complications, the two groups had comparable hospital mortality and similar satisfactory rates of graft survival and patient overall survival. Therefore, a high MELD score should not be a contraindication to right-lobe LDLT if donor risk and recipient benefit are taken into full account.

Model for End-stage Liver Disease

Model for end-stage liver disease (MELD) score, initially developed to predict survival following transjugular intrahepatic portosystemic shunt was subsequently found to be accurate predictor of mortality amongst patents with end-stage liver disease. Since 2002, MELD score using 3 objective variables (serum bilirubin, serum creatinine, and institutional normalized ratio) has been used worldwide for listing and transplanting patients with end-stage liver disease allowing transplanting sicker patients first irrespective of the wait time on the list. MELD score has also been shown to be accurate predictor of survival amongst patients with alcoholic hepatitis, following variceal hemorrhage, infections in cirrhosis, after surgery in patients with cirrhosis including liver resection, trauma, and hepatorenal syndrome (HRS). Although, MELD score is closest to the ideal score, there are some limitations including its inaccuracy in predicting survival in 15-20% cases. Over the last decade, many efforts have been made to further improve and refine MELD score. Until, a better score is developed, liver allocation would continue based on the currently used MELD score.

The relationship between preoperative creatinine clearance and outcomes for patients undergoing liver transplantation: a retrospective observational study

Background

Renal failure with following continuous renal replacement therapy is a major clinical problem in liver transplant recipients, with reported incidences of 3% to 20%. Little is known about the significance of postoperative acute renal failure or acute-on-chronic renal failure to postoperative outcome in liver transplant recipients.

Methods

In this post hoc analysis we compared the mortality rates of 135 consecutive liver transplant recipients over 6 years in our center subject to their renal baseline conditions and postoperative RRT. We classified the patients into 4 groups, according to their preoperative calculated Cockcroft formula and the incidence of postoperative renal replacement therapy. Data then were analyzed in regard to mortality rates and in addition to pre- and peritransplant risk factors.

Results

There was a significant difference in ICU mortality (p=.008), hospital mortality (p=.002) and cumulative survival (p<.0001) between the groups. The highest mortality rate occurred in the group with RRT and normal baseline kidney function (20% ICU mortality, 26.6% hospital mortality and 50% cumulative 1-year mortality, respectively). The hazard ratio in this group was 9.6 (CI 3.2-28.6, p=.0001).

Conclusion

This study shows that in liver transplant recipient’s acute renal failure with postoperative RRT is associated with mortality and the mortality rate is higher than in patients with acute-on-chronic renal failure and postoperative renal replacement therapy.

Liver transplantation in the critically ill: a multicenter Canadian retrospective cohort study

Introduction

Critically ill cirrhosis patients awaiting liver transplantation (LT) often receive prioritization for organ allocation. Identification of patients most likely to benefit is essential. The purpose of this study was to examine whether the Sequential Organ Failure Assessment (SOFA) score can predict 90-day mortality in critically ill recipients of LT and whether it can predict receipt of LT among critically ill cirrhosis listed awaiting LT.

Methods

We performed a multicenter retrospective cohort study consisting of two datasets: (a) all critically-ill cirrhosis patients requiring intensive care unit (ICU) admission before LT at five transplant centers in Canada from 2000 through 2009 (one site, 1990 through 2009), and (b) critically ill cirrhosis patients receiving LT from ICU (n = 115) and those listed but not receiving LT before death (n = 106) from two centers where complete data were available.

Results

In the first dataset, 198 critically ill cirrhosis patients receiving LT (mean (SD) age 53 (10) years, 66% male, median (IQR) model for end-stage liver disease (MELD) 34 (26-39)) were included. Mean (SD) SOFA scores at ICU admission, at 48 hours, and at LT were 12.5 (4), 13.0 (5), and 14.0 (4). Survival at 90 days was 84% (n = 166). In multivariable analysis, only older age was independently associated with reduced 90-day survival (odds ratio (OR), 1.07; 95% CI, 1.01 to 1.14; P = 0.013). SOFA score did not predict 90-day mortality at any time. In the second dataset, 47.9% (n = 106) of cirrhosis patients listed for LT died in the ICU waiting for LT. In multivariable analysis, higher SOFA at 48 hours after admission was independently associated with lower probability of receiving LT (OR, 0.89; 95% CI, 0.82 to 0.97; P = 0.006). When including serum lactate and SOFA at 48 hours in the final model, elevated lactate (at 48 hours) was also significantly associated with lower likelihood of receiving LT (0.32; 0.17 to 0.61; P = 0.001).

Conclusions

SOFA appears poor at predicting 90-day survival in critically ill cirrhosis patients after LT, but higher SOFA score and elevated lactate 48 hours after ICU admission are associated with a lower probability receiving LT. Older critically ill cirrhosis patients (older than 60) receiving LT have worse 90-day survival and should be considered for LT with caution.

MELD-based graft allocation system fails to improve liver transplantation efficacy in a single-center intent-to-treat analysis

BACKGROUND

Since March 2007, priority access to liver transplantation in France has been given to patients with the highest MELD scores.

OBJECTIVE

To undertake an intent-to-treat comparison of center-based vs. MELD-based liver graft allocation.

METHODS

Retrospective cohort analysis (patients listed 6th March 2007 to 5th March 2009; MELD period) with a matched historical cohort (patients listed 6th March 2005 to 5th March 2007; pre-MELD period) in a single high-volume center. Analysis was on an intent-to-treat basis, i.e. starting on the day of wait listing.

RESULTS

Compared to pre-MELD, fewer patients with a MELD score less or equal to 14 (P=0.002), and more patients with a MELD greater or equal to 24 (P<0.05) were transplanted during the MELD period. For HCC candidates, median waiting time increased (121 vs. 54 days, P=0.01), transplantation rate halved (35% vs. 73.5%, P<0.001) and dropouts due to tumor progression increased (16% vs. 0%, P<0.001). Moreover, postoperative course did not change significantly except for infectious complications (35% vs. 24%, P=0.02); overall patient survival was 69.8 ± 3.1% vs. 76 ± 2.9% (P=0.29) and overall graft survival was 77.6 ± 3.4% vs. 82.8 ± 2.9% (P=0.29). Transplant failures were mainly due to deaths on the waiting list in the previous system, but to dropouts related to disease progression in the new system. Cirrhotic patient survival rate did not change (78.1 ± 4.4% vs. 73.5 ± 4.5%, P=0.42), while that of HCC patients decreased (65.3 ± 5.3% vs. 86.8 ± 4.4%, P=0.01). Post-transplant survival worsened significantly according to pre-transplant MELD score (P=0.009).

CONCLUSION

The MELD-based graft allocation system introduced discrimination against HCC patients, whose incidence has increased dramatically, and should be reevaluated.

Liver transplantation in adults: Choosing the appropriate timing

Liver transplantation is indicated in patients with acute liver failure, decompensated cirrhosis, hepatocellular carcinoma and rare liver-based genetic defects that trigger damage of other organs. Early referral to a transplant center is crucial in acute liver failure due to the high mortality with medical therapy and its unpredictable evolution. Referral to a transplant center should be considered when at least one complication of cirrhosis occurs during its natural history. However, because of the shortage of organ donors and the short-term mortality after liver transplantation on one hand and the possibility of managing the complications of cirrhosis with other treatments on the other, patients are carefully selected by the transplant center to ensure that transplantation is indicated and that there are no medical, surgical and psychological contraindications. Patients approved for transplantation are placed on the transplant waiting list and prioritized according to disease severity. Thus, the appropriate timing of transplantation depends on recipient disease severity and, although this is still a matter of debate, also on donor quality. These two variables are known to determine the “transplant benefit” (i.e., when the expected patient survival is better with, than without, transplantation) and should guide donor allocation.

Is a mandatory intensive care unit stay needed after liver transplantation? Feasibility of fast-tracking to the surgical ward after liver transplantation

The continuation of hemodynamic, respiratory, and metabolic support for a variable period after liver transplantation (LT) in the intensive care unit (ICU) is considered routine by many transplant programs. However, some LT recipients may be liberated from mechanical ventilation shortly after the discontinuation of anesthesia. These patients might be appropriately discharged from the postanesthesia care unit (PACU) to the surgical ward and bypass the ICU entirely. In 2002, our program started a fast-tracking program: select LT recipients are transferred from the operating room to the PACU for recovery and tracheal extubation with a subsequent transfer to the ward, and the ICU stay is completely eliminated. Between January 1, 2003 and December 31, 2007, 1045 patients underwent LT at our transplant program; 175 patients were excluded from the study. Five hundred twenty-three of the remaining 870 patients (60.10%) were fast-tracked to the surgical ward, and 347 (39.90%) were admitted to the ICU after LT. The failure rate after fast-tracking to the surgical ward was 1.90%. The groups were significantly different with respect to the recipient age, the raw Model for End-Stage Liver Disease (MELD) score at the time of LT, the recipient body mass index (BMI), the retransplantation status, the operative time, the warm ischemia time, and the intraoperative transfusion requirements. A multivariate logistic regression analysis revealed that the raw MELD score at the time of LT, the operative time, the intraoperative transfusion requirements, the recipient age, the recipient BMI, and the absence of hepatocellular cancer/cholangiocarcinoma were significant predictors of ICU admission. In conclusion, we are reporting the largest single-center experience demonstrating the feasibility of bypassing an ICU stay after LT.