Novel benchmark values for redo liver transplantation – does the outcome justify the effort?

Objective

In the era of organ shortage, redo liver transplantation (reLT) is frequently discussed in terms of expected poor outcome, high cost and therefore wasteful resources. However, there is a lack of benchmark data to reliably assess outcomes after reLT. The aim of this study was to define the ideal reLT case, and to establish clinically relevant benchmark values for best achievable outcome in reLT.

Methods

We collected data on reLT between January 2010 and December 2018 from 22 high volume transplant centers on three continents. Benchmark cases were defined as recipients with model of end-stage liver disease score <=25, absence of portal vein thrombosis, no mechanical ventilation before surgery, receiving a graft from a donor after brain death. In addition, early reLT including those for primary non-function (PNF) were excluded. Clinically relevant endpoints covering intra- and postoperative course were selected and complications were graded by severity using the Clavien-Dindo classification and the comprehensive complication index (CCI). The benchmark cutoff for each outcome was derived from the 75th percentile of the median values of all benchmark centers, indicating the “best achievable” result. To assess the utility of the newly established benchmark values, we analyzed patients who received reLT for PNF (non-benchmark patients).

Results

Out of 1110 reLT 413 (37.2%) qualified as benchmark cases. Benchmark values included: Length of intensive care unit and hospital stay: <=6 and <=24 days, respectively; Clavien-Dindo grade >=3a complications and the CCI at 1 year: <=76% and <=72.2, respectively; in-hospital and 1-year mortality rates: <=14.0% and <=14.3%, respectively. The cutoffs for transplant-specific complications such as biliary complications at 1 year, outflow problems at 1 year and hepatic artery thrombosis at discharge were <=27.3%, <=2.5% and <=4.8%, respectively. Patients receiving a reLT for PNF showed mean outcome values all outside the reLT benchmark values. In-hospital mortality rate was 34.4% and the mean CCI at discharge 68.8.

Conclusion

ReLT remains associated with high morbidity and mortality. The availability of benchmark values for outcome parameters of reLT may serve for comparison in any future analyses of individuals, patient groups, or centers, but also in the evaluation of new therapeutic strategies and principles.

Glycosidases in Leishmania and their importance for Leishmania in phlebotomine sandflies with special reference to purification and characterization of a sucrase

Culture forms of Leishmania (Leishmania) amazonensis (IFLA/BR/67/PH8) produce an extracellular enzyme that hydrolyzes sucrose molecules into their component monosaccharides. This is important because phlebotomine sand flies, the invertebrate hosts of Leishmania, ingest plant sap or aphid and coccid honeydew rich in sucrose between blood meals and Leishmania promastigotes cannot uptake sucrose. The sucrase was purified and characterized; its molecular weight, estimated by gel filtration chromatography and SDS-PAGE electrophoresis, was about 73 kDa. K(m) and V(max) measured with sucrose as substrate were respectively 4.4 mM and 6.9 mumole glucose.min-1 (mg sucrase)-1, with maximum pH activity at pH 5.5. A series of natural and p-nitrophenyl-derived substrates were assayed, characterizing the enzyme as a highly specific beta-D-fructofuranoside fructohydrolase. When 11 species of Leishmania and 7 genera of trypanosomatids were screened, only the species of the genus Trypanosoma did not produce an enzyme with saccharolytic activity. These data are in agreement with the fact that the latter vectors do not acquire sucrose or raffinose in their meals. Searching for glycolytic enzymes other than sucrase, we found an N-acetyl-beta-D-galactosaminolytic activity. This N-acetyl-galactosaminidase, here described for the first time, might have a role in peritrophic membrane disruption. The importance of sucrase and N-acetyl-beta-D-galactosaminidase in the Leishmania life cycle is discussed.