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.

Is Elective Status a Predictor of Poor Survival in Liver Retransplantation?

BACKGROUND: Orthotopic liver retransplantation (reLT) is considered to have poorer outcomes than primary transplantation. The objective of this study was to analyze the impact of medical urgency status as a predictor of patient survival after reLT. METHODS: Forty-nine patients who underwent reLT were included in this retrospective study. Urgent or elective status was based on the judgment of the surgical team, selected variables, and the Model for End-Stage Liver Disease score. Multivariate analysis was performed to identify variables associated with patient survival following reLT. RESULTS: Overall survival of the patient cohort was 57% at 1 year and 54.3% at 3 years after reTL. Survival in urgent-status patients was 68.8% and 63.4% at 1 and 3 years, respectively, whereas the survival rate for elective patients was 40.0% at both time points. Mortality was significantly associated with elective status (hazard ratio [HR], 2.42; P = .046) at 1 year, but was no longer significant (HR, 2.19; P < .069) after 3 years of follow-up. CONCLUSIONS: Elective status is associated with poorer outcome. Patient selection determines long-term survival more than any other single factor, so for patients designated to an elective status, prompt retransplantation should be encouraged.

Results of liver transplantation from old donors.

INTRODUCTION: Faced with a shortage of organs for liver transplantation, the use of grafts from older donors is justified. However, there remains little consensus on how this use impacts the graft and patient outcomes after transplantation from these older donors. The aim of the present analysis was to assess the graft and patient outcomes after liver transplantation from deceased donors >60 years of age. METHODS: From January 2007 to January 2011, 505 subjects were identified as liver graft donors after brain death, of which 7.35% were ≥60. To determine the effect of donor age on graft and patient outcomes, we analyzed donor age, recipient age, the Model for End-State Liver Disease (MELD) score of recipients at the time of transplantation, early posttransplant complications, and mortality. RESULTS: The posttransplant follow-up was 29 ± 25.5 months, and 3-year patient mortality from donors, grouped according to age, was 7.92% with donors <30; 15.78% with donors 30-50, 10.68% with donors 50-60, and 12.50% with donors >60. After analysis of patient and graft survival based on donor graft age, 3-year patient survival according donor age was 89.29% with donors <30, 83.85% with donors 30-50, 89.89% with donors 50-60, and 87.50% with donors >60. Analysis showed overall patient and graft survival rates from older donors were not worse than those from younger donors (P > .1). Among the cases, 3-year patient survival according to MELD score was 91.19% with a MELD of I, 85.37% with a MELD of II, and 67.67% with a MELD of III; differences in graft and patient survival when comparing low MELD I and high MELD III were significantly different (P < .01). CONCLUSIONS: A more advanced age of a donor should not be a contraindication for liver transplantation. The present analysis shows that liver grafts from donors >60 can be used safely in older recipients who presented with relatively low MELD scores. Analyses also indicate that high MELD obtained before transplantation may be an important prognostic factor for graft and patient survival.

Poor outcomes after liver transplantation in patients with incidental cholangiocarcinoma irrespective of tumor localization.

INTRODUCTION: After liver transplantation for cholangiocarcinoma (CCC), patients have a poor prognosis without use of specific therapeutic strategies. Accordingly, recipients with incidental CCC might have the highest risk of recurrent disease; however, sparse data on the long-term outcome of unselected patients with incidental CCC have been published. The aim of this study was to evaluate the post-transplantation outcomes of patients with incidental CCC with special focus on tumor localization. MATERIAL AND METHODS: There were 11 primary liver transplantations in patients with incidental CCC of 1310 liver transplantation procedures performed between December 1994 and August 2013. All patients with incidental CCC received a chemotherapy regiment including gemcitabine/5 fluorouracil, doxorubicin, and mitomycin. The patients were switched from calcineurin inhibitors to mammalian target of rapamycin inhibitor-based immunosuppression shortly after CCC diagnosis. RESULTS: Intra- and extrahepatic tumors were found in 6 and 5 patients, respectively. At median follow-up examination of 26.3 months there were 8 CCC recurrences and 7 patient deaths. Overall survival after liver transplantation for incidental CCC was 88.9% at 1 year, 44.4% at 2 years, and 14.8% at 3 years. The corresponding rates of recurrence-free survival were 45.7%, 45.7%, and 0.0%, respectively. Post-transplantation CCC recurrences were universal with 0% 3-year recurrence-free survival both in patients with intra- and extrahepatic tumors (P = .475). CONCLUSIONS: Incidental CCC in liver transplantation is associated with poor outcomes irrespective of tumor localization. Introduction of new adjuvant multimodal treatment concepts is necessary to improve the prognosis for this subgroup of patients.

Evaluation of total tumor volume and pretransplantation α-fetoprotein level as selection criteria for liver transplantation in patients with hepatocellular cancer.

INTRODUCTION: Appropriate selection of hepatocellular cancer (HCC) patients for liver transplantation is crucial to minimize the risk of recurrence and provide long-term outcomes comparable with those for other indications. Selection criteria based on total tumor volume (TTV) and α-fetoprotein (AFP) concentrations were proposed in a recent large study. The aim of this study was to evaluate the results of liver transplantation for HCC within and beyond these criteria. MATERIAL AND METHODS: This retrospective study included 104 patients with HCC who underwent liver transplantation. Risk factors for overall survival and tumor recurrence were evaluated. Overall survival and cumulative tumor recurrence rate for patients with TTV <115 cm(3), AFP concentration <400 ng/mL, and no macrovascular invasion (76/104; 73.1%) were evaluated and compared with those for the remaining patients (28/104; 26.9%). RESULTS: Pretransplantation AFP concentration >400 ng/mL (P = .016; hazard ratio [HR], 3.36; 95% confidence intervals [CI], 1.25-9.03) was the only risk factor for overall survival. TTV >115 cm(3) (P = .021; HR 4.29; 95% CI, 1.24-14.81) and AFP concentration >400 ng/mL (P = .002; HR 6.97; 95% CI, 2.02-24.03) were independent risk factors for recurrence. The estimated 3-year tumor recurrence rate was 4.2% for patients with TTV <115 cm(3), AFP concentration <400 ng/mL, and no macrovascular invasion compared with 57.2% for the remaining patients (P < .00001). The 3-year overall survival rate of patients within and beyond this criteria was 81.7% and 64.6%, respectively (P = .0628). CONCLUSIONS: In contrast to other criteria, selection of HCC patients for liver transplantation on the basis of TTV and AFP concentration relates to both morphological features and tumor biology. Although fulfillment of these criteria was more than 1.5-fold higher than that of the Milan criteria, the rate of tumor recurrence was exceptionally low.

Radiofrequency assisted liver resection: analysis of 604 consecutive cases.

BACKGROUND: Intraoperative blood loss is an important factor contributing to morbidity and mortality in liver surgery. To address this we developed a bipolar radiofrequency (RF) device, the Habib 4X, used specifically for hepatic parenchymal transection. The aim of this study was to prospectively assess the peri-operative data using this technique. METHODS: Between 2001 and 2010, 604 consecutive patients underwent liver resections with the RF assisted technique. Clinico-pathological and outcome data were collected and analysed. RESULTS: There were 206 major and 398 minor hepatectomies. Median intraoperative blood loss was 155 (range 0-4300)ml, with a 12.6% rate of transfusion. There were 142 patients (23.5%) with postoperative complications; none had bleeding from the resection margin. Only one patient developed liver failure and the mortality rate was 1.8%. CONCLUSIONS: RF assisted liver resection allows major and minor hepatectomies to be performed with minimal blood loss, low blood transfusion requirements, and reduced mortality and morbidity rates.

Prediction of graft loss and death in patients with primary sclerosing cholangitis.

BACKGROUND: The prognosis of patients with primary sclerosing cholangitis (PSC) can be accurately determined using the Mayo Clinic Score (MRS), a mathematical model which predicts patient survival. The purpose of our study was to determine the risk of graft loss and/or death among patients who were listed or transplanted because of PSC. PATIENTS AND METHODS: We analyzed the data of 52 patients, who were placed on the transplant list due to PSC between January 2000 and November 2008 and either did or did not undergo liver transplantation (OLT). The primary end point (EP1) of the study was the patient death for any cause. The secondary end point (EP2) was recurrence of PSC or appearance of CCC or death related to the primary liver disease after OLT (PSC recurrence). The observation time was 60 months. According to the calculated MRS, patients were divided into 3 groups: group A (MRS < 0.56); group B (0.56 < or = MRS < 1.56), and group C (MRS > 1.56). The analysis was performed using the LIFETEST and PHREG Procedures of the SAS System. RESULTS: The risk of EP1 occurrence was 2.0 per 1 point of MRS (P < .0006). The risk of EP2 was 2.1 per 1 point of MRS (P < .001). Groups B and C compared with group A showed risks of death of: 0.79 (P = NS) and 6.59 (P < .08), respectively. The percentage of 5-year patient survival rate were 94%, 94%, and 45% according to groups A, B, and C, respectively. CONCLUSION: The risk of death in patients with MRS > 1.56 was 6.59-fold higher than those with MRS < 0.56. MRS > 1.56 significantly decreased 5 year survival among patients with primary sclerosing cholangitis.

Impact of tumor characteristic on the outcome of liver transplantation in patients with hepatocellular carcinoma.

INTRODUCTION: Orthotopic liver transplantation (OLT) is a well-established treatment for cirrhotic patients with hepatocellular carcinoma (HCC) who meet the Milan criteria. The aim of this study was to identify predictors of survival among 65 patients with HCC in cirrhotic livers who underwent liver transplantation (OLT). METHODS: From January 2001 to December 2008, we performed 655 OLT in 615 patients. HCC was diagnosed in 58 patients before OLT and in 65 by histological examination of the explanted livers; 74% of the patients met Milan criteria by histological examination. RESULTS: The median follow-up was 27 months (range = 1-96). We analyzed patient age and gender, etiology of liver disease, Child score at transplantation, rejection episodes, tumor number/size, vascular invasion, and differentiation grade. There was no significant difference in survival among patients grouped according to the Model for End-stage Liver Disease staging system for HCC. The 5-year survival of patients with low differentiated (G3) HCC was significantly worse than that of those with moderately differentiated (G2) or well-differentiated (G1) HCC: 50%, 81%, and 86% respectively, (P < .01). Patients with microvascular invasion displayed a worse 5-year survival than those without vascular invasion (42% vs 80%; P < .01). CONCLUSIONS: The analysis indicated that the histological grade of the tumors and evidences of microscopic vascular invasion were the most useful predictive factors for overall survival among patients with cirrhosis after liver transplantation for HCC.

Low incidence of hepatic artery thrombosis after hepatic artery reconstruction during liver transplantation.

BACKGROUND: Hepatic artery thrombosis (HAT) remains an important cause of graft loss after liver transplantation. HAT can be caused by technical, hemodynamic, or immunologic factors. Bench reconstruction of anatomical variants of the hepatic artery is considered to fore a major risk related to HAT. The purpose of the study was to analyze the influence on HAT of hepatic artery vascular reconstruction. METHODS: We retrospectively analyzed 341 donor forms completed between January 2004 and December 2007. Vascular reconstruction was defined as an additional anastomosis between donor hepatic arteries, which was required to fully revascularize the graft. Any incident of HAT was confirmed by angiography and intraoperatively during retransplantation. Fisher's exact test and 95% confidence intervals (CI) were applied for statistical analysis. RESULTS: Among 341 grafts hepatic artery anomalies observed, variations were recorded in 92 cases (26.9%), of whom 35.9% required hepatic artery reconstruction. HAT was diagnosed in 3% (1/33) hepatic reconstructions (CI, 0.1%-15.8%) compared with 1.6% of grafts (5/308) that did not required hepatic reconstruction (P < or = .45). The 1 case of hepatic thrombosis (1/59) accounting for 1.6% among the group with hepatic anomalies without reconstruction (CI, 0.04%-9.1%). CONCLUSION: A single hepatic reconstruction was a nonsignificant factor for HAT. Hepatic artery reconstruction did not increase the risk of HAT compared with the normal blood supply. Hepatic artery anomalies did not significantly increase the incidence of HAT compared with the group of patients without arterial variations.

Early expression of hepatocyte growth factor, interleukin-6, and transforming growth factor-beta1 and -beta2 in symptomatic infection in patients who have undergone liver transplantation.

INTRODUCTION: Early septic complications may be a deciding factor for successful recovery among patients who have undergone orthotopic liver transplantation. Therefore, monitoring liver function parameters plays an important role in postoperative treatment to achieve an early diagnosis of postsurgical complications. We ought to measure standard liver function parameters and the expression levels for selected cytokines among patients exhibiting symptoms of infection after orthotopic liver transplantation. MATERIALS AND METHODS: The study was performed on 30 patients who were divided into two groups: SI-0 consisted of patients free of infection, and SI-1, those who had symptoms of infection. We determined standard liver function parameters and expression of hepatocyte growth factor (HGF), interleukin (IL)-6, transforming growth factor (TGF)-beta1, and TGF-beta2. RESULTS: There were no significant differences in standard liver function parameters between the two groups of patients. There were no significant differences in the levels of expression for the cytokines in question between the two groups of patients. CONCLUSIONS: Although standard liver function parameters provide diagnostically valuable information on the patient's condition, they cannot be used to determine the extent of systemic infection among patients showing signs of infection after liver transplantation. Determining gene expression levels in circulating lymphocytes is a sensitive method to monitor patients' condition after liver transplantation. The expression levels of HGF, IL-6, TGF-beta1, and TGF-beta2 in circulating lymphocytes were not sufficiently specific to diagnose transitory postsurgical complications such as symptomatic infection.

Choice of transplantation techniques and indications for liver transplantation in polycystic liver disease in patients with no signs of end-stage liver disease.

OBJECTIVE: Since the initiation of the Liver Transplant Program, 500 liver procedures have been performed. Polycystic liver disease (PLD) and polycystic kidney-liver disease (PKLD) have been rare indications for orthotopic liver transplantation (OLT). Only 7 patients (1.4%) underwent transplantation due to PLD and PKLD. MATERIALS AND METHODS: The group consisted of 4 patients who underwent OLT (0.8%) and 3 patients who received simultaneous liver kidney transplantation (LKT; 0.6%). Our objective was to analyze the indications for either OLT or combined LKT as well as indications for surgical techniques during OLT among patients with PLD or PKLD. RESULTS: The main indication for OLT was massive hepatomegaly causing severe physical handicaps, fatigue, and clinically advanced malnutrition. All 3 patients with indications for combined LKT were dialysis-dependent. None of the patients had symptoms of end-stage liver disease and/or hepatic failure. In 4 cases, a portal bypass was applied, and the piggy-back method used in the other 3 cases. The hepatectomy caused no uncommon difficulty. In cases of simultaneous transplantations, the kidney was implanted separately after OLT. All patients are alive following the transplantation; major surgical complications have occurred. CONCLUSIONS: Patients with PLD can undergo OLT safely with good results. They benefit from the relief of abdominal distension and anorexia. Patients with PKLD who are dialysis-dependent should undergo simultaneous LKT. The surgical technique was solely dependent on the intraoperative conditions determined during the dissection phase.

Biliary complications in relation to the technique of biliary reconstruction in adult liver transplant recipients.

UNLABELLED: Biliary complications are known as a weak point of liver transplantation. Their occurrence can be related to the practice of draining the biliary anastomosis performed at the time of transplantation. At our institution, routine of anastomotic biliary drainage was abandoned in June 2004. AIM: We sought to assess the occurrence and character of biliary complications following orthotopic liver transplantation in relation to the technique of anastomosis. MATERIALS AND METHODS: In two groups of transplantees: last 100 transplantations with biliary drainage (48 females and 52 males aged 17 to 64 years) and last 100 transplantations without drainage (52 females and 48 males aged 18 to 67 years). The results of treatment were compared, for biliary complications and their influence on further management. In both groups, the main indications for transplantation were various types of cirrhosis as well as cholestatic diseases. In most cases (167) we performed a cholangiojejunal Roux-en-Y (CBD) end-to-end anastomosis, less commonly (33 cases) hepaticojejunal anastomoses. RESULTS: In the first group, biliary complications (bile leak at the site of drainage, bile leak after T-tube removal, CBD strictures) requiring surgical or endoscopic intervention, occurred in 17% recipients. In one case, the biliary complication resulted in retransplantation. In the second group, biliary complications occurred in 11% patients. None of them caused organ loss. CONCLUSION: Abandoning drainage of the biliary anastomosis has reduced the occurrence of early biliary complications after orthotopic liver transplantation.

Clinical significance of lymphocytes hepatocyte growth factor mRNA expression in patients after liver transplantation.

UNLABELLED: Hepatocyte growth factor (HGF) plays a key role in the regulation of liver regeneration after hepatocyte damage. Changes in HGF gene expression reflect the status of the regeneration process. AIM: The aim of this study was to ascertain the clinical significance of the expression of HGF among liver transplant patients. METHODS: Expression of the mRNA of HGF among peripheral blood lymphocytes were measured prior to as well as at 1, 2, 6, and 10 days after liver transplantation in a group of 30 liver recipients. RESULTS: In first 24 hours after reperfusion, the patients with compromised graft function (group 1) showed persistently higher HGF gene expression after reperfusion compared with patients displaying well-functioning grafts (group 0; P = .0189). Between postoperative days 1 and 10, there was a rapid decrease in gene expression among group 0 compared with group 1 (P = .0155). The significant decrease observed in the both groups reached a certain plateau after 48 hours postoperatively. There was no statistical difference in aminotransaminase levels over the days after liver transplantation. The decreased mRNA HGF expression in lymphocytes preceded the decrease in aminotransferase levels. CONCLUSIONS: HGF was more sensitive to predict early graft function than prothrombin time, aspartate aminotransferase, and alanine aminotransferase levels. The determination of HGF expression level in lymphocytes after liver transplantation may yield valuable information for evaluation of early graft function.

Assessment of early biliary complications after orthotopic liver transplantation and their relationship to the technique of biliary reconstruction.

INTRODUCTION: Biliary complications are known as the weak point of liver transplantation. Their occurrence can be related to the practice of drainage of the biliary anastomosis, the routine use of which was abandoned in June 2004. The aim of the study was to assess the incidence and type of biliary complications following orthotopic liver transplantation in relation to the technique of biliary anastomosis. MATERIAL AND METHODS: We compared the results of two groups of adult liver transplant recipients: group I, recent 50 transplantations with biliary drainage (25 women: 25 men of age range: 17 to 63 years), and group II, first 50 transplantations without drainage (19 women and 31 men of age range, 20 to 65 years). We examined the problem of biliary complications and their influence on the further management of the patients. In both groups the main indications for transplantation were various types of cirrhosis as well as cholestatic diseases. In the majority of cases (n = 86) an end-to-end common bile duct anastomosis was performed and in 14 cases, hepaticojejunal anastomosis. RESULTS: In group I, biliary complications requiring surgical or endoscopic intervention occurred in 10 (20%) recipients. In one case, biliary complications resulted in the need for retransplantation. In group II, biliary complications occurred in only four (8%) patients, none of which caused organ loss. CONCLUSION: Cessation of biliary anastomosis drainage has reduced the occurrence of early biliary complications following orthotopic liver transplantation.

Anatomical alteration of the vascular tree observed during living related liver transplantation.

INTRODUCTION: The number of available cadaveric donor organs has reached a plateau. One current solution has been to increase number of living related liver transplantations. MATERIAL AND METHODS: Since October 1999 in the Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 40 living related liver transplantation have been carried out. RESULTS: In 31 (77.5%) cases, a normal arterial supply was observed: the common hepatic artery arose from a celiac trunk. In two cases (5.0%), there was a partial arterial blood supply by the right accessory hepatic artery originating from the superior mesenteric artery. In two cases (5.0%), a right hepatic artery arose completely from the superior mesenteric artery (replaced artery). In one case (2.5%), a common hepatic artery originated from the superior mesenteric artery. In two cases (5.0%), an accessory left segmental artery originated from the left gastric artery. In two cases (5.0%), the function of an absent left hepatic artery was assumed by a replaced left hepatic artery originating from the left gastric artery. In two (5.0%) cases, there were two separate ducts draining the right hemiliver. There were two (5.0%) cases of an accessory duct draining segment IV, originating within the confluence of the right and left hepatic ducts. In one (2.5%) case, the common hepatic duct showed a trifurcation. CONCLUSION: During harvesting from a living donor knowledge of anatomical variants must be used to optomize the liver graft.

The impact of experience of a transplantation center on the outcomes of orthotopic liver transplantation.

The so-called learning factor has been disregarded for many years in analyzing the causes of surgical complications and post-operative mortality; it is also the case for OLT. In our center until April 2003, 209 OLT were performed in 196 patients. We evaluated the impact of experience of the transplantation team on the outcomes of liver transplantation. Thirty-four patients died (mortality rate, 16%) and 1-year survival rate, 64%. Mortality rates varied during different periods of observation due to increasing experience of the transplantation team. The causes of mortality were assessed for a series of 34 patients: it was 75% at the beginning of transplantation procedures while recent deaths have not recently exceeded 10% of cases.