C-Reactive Protein as Predictor for Infectious Complications after Robotic and Open Esophagectomies.

INTRODUCTION: The value of C-reactive protein (CRP) as a predictor of anastomotic leakage (AL) after esophagectomy has been addressed by numerous studies. Despite its increasing application, robotic esophagectomy (RAMIE) has not been considered separately yet in this context. We, therefore, aimed to evaluate the predictive value of CRP in RAMIE. MATERIAL AND METHODS: Patients undergoing RAMIE or completely open esophagectomy (OE) at our University Center were included. Clinical data, CRP- and Procalcitonin (PCT)-values were retrieved from a prospectively maintained database and evaluated for their predictive value for subsequent postoperative infectious complications (PIC) (AL, gastric conduit leakage or necrosis, pneumonia, empyema). RESULTS: Three hundred and five patients (RAMIE: 160, OE: 145) were analyzed. PIC were noted in 91 patients on postoperative day (POD) 10 and 123 patients on POD 30, respectively. Median POD of diagnosis of PIC was POD 8. Post-operative CRP-values in the robotic-group peaked one and two days later, respectively, and converged from POD 5 onward compared to the open-group. In the group with PIC, CRP-levels in the robotic-group were initially lower and started to differ significantly from POD 3 onward. In the open-group, increases were already noticed from POD 3 on. Procalcitonin levels did not differ. Best Receiver operating curve (ROC)-results were on POD 4, highest negative predictive values at POD 5 (RAMIE) and POD 4 (OE) with cut-off values of 70 mg/L and 88.3 mg/L, respectively. CONCLUSION: Post-operative CRP is a good negative predictor for PIC, after both RAMIE and OE. After RAMIE, CRP peaks later with a lower cut-off value.

Eso-Sponge® for anastomotic leakage after oesophageal resection or perforation: outcomes from a national, prospective multicentre registry.

BACKGROUND: Anastomotic leakage (AL) after oesophagectomy and oesophageal perforations are associated with significant morbidity and mortality. Minimally invasive endoscopy is often used as first-line treatment, particularly endoluminal vacuum therapy (EVT). The aim was to assess the performance of the first commercially available endoluminal vacuum device (Eso-Sponge®) in the management of AL and perforation of the upper gastrointestinal tract (GIT). METHODS: The Eso-Sponge® registry was designed in 2014 as a prospective, observational, national, multicentre registry. Patients were recruited with either AL or perforation within the upper GIT. Data were collected with a standardized form and transferred into a web-based platform. Twenty hospitals were enrolled at the beginning of the study (registration number NCT02662777; http://www.clinicaltrials.gov). The primary endpoint was successful closure of the oesophageal defect. RESULTS: Eleven out of 20 centres recruited patients. A total of 102 patients were included in this interim analysis; 69 patients with AL and 33 with a perforation were treated by EVT. In the AL group, a closure of 91 per cent was observed and 76 per cent was observed in the perforation group. The occurrence of mediastinitis (P = 0.002) and the location of the defect (P = 0.008) were identified as significant predictors of defect closure. CONCLUSIONS: The Eso-Sponge® registry offers the opportunity to collate data on EVT with a uniform, commercially available product to improve standardization. Our data show that EVT with the Eso-Sponge® is an option for the management of AL and perforation within the upper GIT.

[Robot-assisted Minimally Invasive Oesophagectomy (RAMIE) - Setup, Port Placement, Stepwise Procedure Guide]. / Robotische Ösophaguresektion (RAMIE) ­ Setup, Port Placement, strukturierte OP-Schritte.

Robot-assisted minimally invasive oesophagectomy (RAMIE) can overcome the limitations of thoracoscopic surgery, particularly in the thoracic part of the operation. Thanks to more degrees of freedom of movement, anastomosis is simpler in the robotic procedure. In this work, we present our established full RAMIE-technique on the da Vinci Xi® system. Our technique is characterized by the incomplete formation of the gastric tube abdominally and an end-to-side anastomosis with a circular stapler.

Development and validation of a prognostic model for kidney function 1 year after combined pancreas and kidney transplantation using pre-transplant donor and recipient variables.

PURPOSE: The widening gap between demand and supply of organs for transplantation provides extraordinary challenges for ethical donor organ allocation rules. The transplant community is forced to define favorable recipient/donor combinations for simultaneous kidney-pancreas transplantation. The aim of this study is the development of a prognostic model for the prediction of kidney function 1 year after simultaneous pancreas and kidney transplantation using pre-transplant donor and recipient variables with subsequent internal and external validation. METHODS: Included were patients with end-stage renal failure due to diabetic nephropathy. Multivariable logistic regression modeling was applied for prognostic model design with retrospective data from Hannover Medical School, Germany (01.01.2000-31.12.2011) followed by prospective internal validation (01 Jan. 2012-31 Dec. 2015). Retrospective data from another German transplant center in Kiel was retrieved for external model validation via the initially derived logit link function. RESULTS: The developed prognostic model is able to predict kidney graft function 1 year after transplantation ≥ KDIGO stage III with high areas under the receiver operating characteristic curve in the development cohort (0.943) as well as the internal (0.807) and external validation cohorts (0.784). CONCLUSION: The proposed validated model is a valuable tool to optimize present allocation rules with the goal to prevent transplant futility. It might be used to support donor organ acceptance decisions for individual recipients.

Evolutionary Distance Predicts Recurrence After Liver Transplantation in Multifocal Hepatocellular Carcinoma.

BACKGROUND: Liver transplantation (LTx) is a potentially curative treatment option for hepatocellular carcinoma (HCC) in cirrhosis. However, patients, where HCC is already a systemic disease, LTx may be individually harmful and has a negative impact on donor organ usage. Thus, there is a need for improved selection criteria beyond nodule morphology to select patients with a favorable outcome for LTx in multifocal HCC. Evolutionary distance measured from genome-wide single-nucleotide polymorphism data between tumor nodules and the cirrhotic liver may be a prognostic marker of survival after LTx for multifocal HCC. METHODS: In a retrospective multicenter study, clinical data and formalin-fixed paraffin-embedded specimens of the liver and 2 tumor nodules were obtained from explants of 30 patients in the discovery and 180 patients in the replication cohort. DNA was extracted from formalin-fixed paraffin-embedded specimens followed by genome wide single-nucleotide polymorphism genotyping. RESULTS: Genotype quality criteria allowed for analysis of 8 patients in the discovery and 17 patients in the replication set. DNA concentrations of a total of 25 patients fulfilled the quality criteria and were included in the analysis. Both, in the discovery (P = 0.04) and in the replication data sets (P = 0.01), evolutionary distance was associated with the risk of recurrence of HCC after transplantation (combined P = 0.0002). In a univariate analysis, evolutionary distance (P = 7.4 × 10) and microvascular invasion (P = 1.31 × 10) were significantly associated with survival in a Cox regression analysis. CONCLUSIONS: Evolutionary distance allows for the determination of a high-risk group of recurrence if preoperative liver biopsy is considered.

Long-term quality of life after endovac-therapy in anastomotic leakages after esophagectomy.

BACKGROUND: Endoluminal vacuum therapy (EVT) has been successfully established with promising survival rates in the treatment of anastomotic leakages after esophagectomy. It is still unclear how this therapy affects health related quality of life (HRQOL). METHODS: HRQOL was prospectively assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) questionnaire. Assessment was carried out prior to surgery, after discharge, 6 months and 12 months after surgery. We compared HRQOL after EVT (n=23) to patients without anastomotic leakages as a control group (n=50). Investigated parameters included age, sex, and localization of anastomosis, number of EVT sessions, length of ICU and hospital stay, therapy failure, anastomotic stricture, tumour stage, neoadjuvant and adjuvant treatment, sepsis. RESULTS: After esophagectomy HRQOL increased within 12 months. Compared to patients without leakages the EVT-group showed significantly better HRQOL-scores for pain, social and emotional functioning after discharge and 6 months after surgery. In the long-term follow up HRQOL was comparable between the groups. After EVT age, advanced tumour stage, tumour recurrence, anastomotic strictures, length of ICU and hospital stay and length of EVT had a significant influence on HRQOL. CONCLUSIONS: EVT is a promising therapeutic option in leakages after esophagectomy. In the long-term, HRQOL of EVT-treated patients is comparable to patients, who did not suffer from postsurgical leakages.

The Glasgow Prognostic Score and its variants predict mortality in living donor but not in deceased donor liver transplantation for hepatocellular carcinoma: A double-center validation study.

AIM: This study aimed to evaluate whether the Glasgow Prognostic Score (GPS) and its variants are able to predict mortality in live donor and deceased donor liver transplantation for hepatocellular carcinoma. METHODS: Data of 29 live donor and 319 deceased donor transplantations from two German transplant centers was analyzed. The GPS, modified GPS, hepatic GPS, and Abe score were investigated. Receiver operating characteristic (ROC) curve analysis was carried out to calculate the sensitivity, specificity, and overall model correctness of the investigated scores as a predictive model. Study end-points were 1-year, 3-year, and long-term mortality. RESULTS: A 1-year mortality of 19.1% (n = 61), 3-year mortality of 26.3% (n = 84), and overall mortality of 37.3% (n = 119) was observed. All investigated scores failed to predict outcome in deceased donor liver transplantation (areas under ROC curves <0.700), whereas GPS, hepatic GPS, modified GPS, and the Abe score reached areas under ROC curves >0.700 for the prediction of 1-year mortality in live donor transplantation. The GPS and Abe score were also able to predict 3-year mortality. None of the investigated scores was a reliable predictor of long-term mortality. CONCLUSION: Systemic inflammation-based scores have great prognostic potential in live donor transplantation. Abe score could be successfully externally validated in the current study for the first time. In deceased donor transplantation, none of the analyzed scores was able to allow reliable prediction for the investigated study end-points.

The new liver allocation score for transplantation is validated and improved transplant survival benefit in Germany but not in the United Kingdom.

Prognostic models for the prediction of 90-day mortality after transplantation with pretransplant donor and recipient variables are needed to calculate transplant benefit. Transplants in adult recipients in Germany (Hannover, n = 770; Kiel, n = 234) and the United Kingdom (Birmingham, n = 829) were used for prognostic model design and validation in separate training and validation cohorts. The survival benefit of transplantation was estimated by subtracting the observed posttransplant 90-day mortality from the expected 90-day mortality without transplantation determined by the Model for End-Stage Liver Disease (MELD) score. A prognostic model called the liver allocation score (LivAS) was derived using a randomized sample from Hannover using pretransplant donor and recipient variables. This model could be validated in the German training and validation cohorts (area under the receiver operating characteristic curve [AUROC] > 0.70) but not in the English cohort (AUROC, 0.58). Although 90-day mortality rates after transplantation were 13.7% in Hannover, 12.1% in Kiel, and 8.3% in Birmingham, the calculated 90-day survival benefits of transplantation were 6.8% in Hannover, 7.8% in Kiel, and 2.8% in Birmingham. Deployment of the LivAS for limiting allocation to donor and recipient combinations with likely 90-day survival as indicated by pretransplant LivAS values below the cutoff value would have increased the survival benefit to 12.9% in the German cohorts, whereas this would have decreased the benefit in England to 1.3%. The English and German cohorts revealed significant differences in 21 of 28 pretransplant variables. In conclusion, the LivAS could be validated in Germany and may improve German allocation policies leading to greater survival benefits, whereas validation failed in England due to profound differences in the selection criteria for liver transplantation. This study suggests the need for national prognostic models. Even though the German centers had higher rates of 90-day mortality, estimated survival benefits were greater. Liver Transplantation 22 743-756 2016 AASLD.

Comparable outcome of liver transplantation with histidine-tryptophan-ketoglutarate vs. University of Wisconsin preservation solution: a retrospective observational double-center trial.

BACKGROUND: The question of whether the choice of preservation solution affects outcome after liver transplantation is still not satisfactorily answered. The purpose of this study is to examine the preservation solutions' impact on outcome after liver transplantation. METHODS: A double-center retrospective study of short- and long-term results of 3134 consecutive liver transplantations with follow-up periods up to 23 years was performed applying multivariate, risk-adjusted analyses with a subset for living-donor transplants, pediatric transplants and cases with prolonged cold ischemic times. An additional focus was put on biliary complications. The primary study endpoints were short- and long-term patient survival and death-censored graft survival. Secondary study endpoints were the occurrence of post-transplant complications, the necessity of operative revisions, the length of hospital stay, and the length of intensive care unit stay. RESULTS: Although long-term graft survival appears to be increased by Histidine-Tryptophan-Ketoglutarate-use (p = 0.018), this effect could not be confirmed in risk-adjusted analysis (p = 0.641). Multivariate regression analysis revealed that 3-month mortality (p = 0.120), 3-month graft survival (p = 0.103) and long-term patient survival (p = 0.235) were not influenced by the choice of preservation solution. There was no difference in the occurrence of common complications or necessity of operative revisions after liver transplantation. This was confirmed in subgroup analyses for living donor and pediatric transplantation and cases with prolonged cold ischemic time. Analysis of the preservation solutions' impact on length of hospital (p = 0.113) and intensive care unit stay (p = 0.481) revealed no significant difference. CONCLUSIONS: University of Wisconsin and Histidine-Tryptophan-Ketoglutarate solutions are clinically equivalent. Histidine-Tryptophan-Ketoglutarate solution could have an economically superior profile. The notion that the choice of preservation solution can have an impact on the onset of biliary complications after liver transplantation remains a matter of controversy.

Value and limitations of the BAR-score for donor allocation in liver transplantation.

PURPOSE: The MELD-score was shown to be able to predict 90-day mortality in most patients with end-stage liver disease prior to liver transplantation and is used as a widely accepted measure for transplantation urgency. Prognostic ability of the BAR-score to predict 90-day post-transplant mortality by detection of unfavourable pretransplant combinations of donor and recipient factors may help to better balance urgency versus utility. METHODS: Two German cohorts (Hannover, n=453; Kiel, n=234) were retrospectively analyzed using ROC-curve analysis, goodness-of-model-fit tests, summary measures and risk-adjusted multivariate binary regression. Included were all consecutive liver transplants performed in adult recipients (minimum age 18 years). Excluded were all combined transplants and living-related organ donor transplants. RESULTS: Risk-adjusted multivariate regression revealed that the BAR-score is an independent risk factor for 90-day mortality after transplantation in both cohorts from Hannover and Kiel combined (p<0.001, OR=1.017, 95% CI:1.031-1.113). The area under the ROC-curve (AUROC) for the prediction of 90-day mortality using the BAR-score was 0.662 (95% CI 0.624-0.699, power>95%). Measures for association between observed 90-day mortality and the predicted probabilities in the combined cohort were concordant in 63.5% with low summary measures (Somers' D test 0.32, Goodman-Kruskal Gamma test 0.34 and Kendall's Tau a test 0.07). CONCLUSIONS: The BAR-score performed below accepted thresholds for potentially useful clinical prognostic models. Prognostic models with better predictive ability with AUROCs>0.700, concordance>70% and larger summary measures are required for the prediction of 90-day post-transplant mortality to enable donor organ allocation with reliable weighing of urgency versus utility.

Massive blood transfusion after the first cut in liver transplantation predicts renal outcome and survival.

INTRODUCTION: Transfusion requirements of blood products may provide useful prognostic factors for the prediction of short-term patient mortality and renal outcome after liver transplantation. PATIENTS AND METHODS: Two hundred ninety-one consecutive liver transplants in adults were analysed retrospectively. Combined and living-related liver transplants were excluded. The amount of transfused packed red blood cells (PRBC) and units of platelets (UP) within the first 48 h were investigated as prognostic factors to predict short-term patient mortality and renal outcome. Receiver operating characteristic (ROC) curve analysis with area under the curve (AUC), Hosmer-Lemeshow tests and Brier scores were used to calculate overall model correctness, model calibration and accuracy of prognostic factors. Cut-off values were determined with the best Youden index. RESULTS: The potential clinical usefulness of PRBC as a prognostic factor to predict 30-day mortality (cut-off 17.5 units) and post-transplant haemodialysis (cut-off 12.5 units) could be demonstrated with AUCs >0.7 (0.712 and 0.794, respectively). Hosmer-Lemeshow test results and Brier scores indicated good overall model correctness, model calibration and accuracy. The UP proved as an equally clinically useful prognostic factor to predict end-stage renal disease (cut-off 3.5 units; AUC = 0.763). The association of cut-off levels of PRBC with patient survival (p < 0.001, log-rank test) and dialysis-free survival (p < 0.001, log-rank test) was significant (cut-off levels 17.5 and 12.5 units, respectively) as well as the association of UP with dialysis-free survival (p < 0.001, log-rank test) (cut-off level 3.5 units). CONCLUSIONS: The impressive discriminative power of these simple prognostic factors for the prediction of outcome after liver transplantation emphasizes the relevance of strategies to avoid excessive transfusion requirements.

Endoscopic endoluminal vacuum therapy in esophageal perforation.

BACKGROUND: Esophageal perforation is a serious disease with a high morbidity and mortality rate. Endoscopic vacuum therapy (EVT) is a new endoscopic treatment option, which is used to treat anastomotic leakages after rectal and esophageal resections. We report on 10 patients treated with EVT for esophageal perforation. METHODS: Clinical and therapy-related data such as age, sex, duration of intensive care stay, length of hospital stay, reasons for perforation, EVT-associated complications, mortality, need for alternative treatment options, and course of infectious variables were analyzed. RESULTS: Ten patients were treated with 54 vacuum sponges that were placed in upper gastrointestinal defects. Causes for perforation were iatrogenic, spontaneous, or foreign body-associated. Mean number of sponge insertions was 5.4 (range, 2 to 12) with a mean period of 19 ± 14.26 days. Successful therapy was achieved in 9 of 10 patients. After successful primary treatment, 1 patient died during therapy as a result of general failure of the cardiovascular system. In 1 patient, surgical resection was necessary after repeated Mallory-Weiss lesions and minor perforations during the course of immunosuppressive therapy. In a third patient an endoscopic stent was inserted in the clean wound cavity after primary EVT. CONCLUSIONS: In this small trial EVT has been shown to be a safe and feasible therapy option for perforations of the upper gastrointestinal tract. If necessary, EVT can be combined with operative revision for better control of the local septic focus or used as a bridging procedure for wound conditioning before aggressive surgical treatment.

Insulin dependence and pancreatic enzyme replacement therapy are independent prognostic factors for long-term survival after operation for chronic pancreatitis.

BACKGROUND: This retrospective, single-center, observational study on postoperative long-term results aims to define yet unknown factors for long-term outcome after operation for chronic pancreatitis. PATIENTS AND METHODS: We analyzed 147 consecutive patients operated for chronic pancreatitis from 2000 to 2011. Mean follow-up was 5.3 years (range, 1 month to 12.7 years). Complete long-term survival data were provided by the German citizen registration authorities for all patients. A quality-of-life questionnaire was sent to surviving patients after a mean follow-up of 5.7 years. RESULTS: Surgical principles were resection (n = 86; 59%), decompression (n = 29; 20%), and hybrid procedures (n = 32; 21%). No significant influences of different surgical principles and operative procedures on survival, long-term quality of life and pain control could be detected. Overall 30-day mortality was 2.7%, 1-year survival 95.9%, and 3-year survival 90.8%. Multivariate Cox regression analysis revealed that only postoperative insulin dependence at the time of hospital discharge (P = .027; Exp(B) = 2.111; 95% confidence interval [CI], 1.089-4.090) and the absence of pancreas enzyme replacement therapy at the time of hospital discharge (P = .039; Exp(B) = 2.102; 95% CI, 1.037-4.262) were significant, independent risk factors for survival with significant hazard ratios for long-term survival. Long-term improvement in quality of life was reported by 55 of 76 long-term survivors (73%). CONCLUSION: Pancreatic enzyme replacement should be standard treatment after surgery for chronic pancreatitis at the time of hospital discharge, even when no clinical signs of exocrine pancreatic failure exist. This study underlines the potential importance of early operative intervention in chronic pancreatitis before irreversible endocrine dysfunction is present.

Prognostic limitations of the Eurotransplant-Donor Risk Index in liver transplantation.

BACKGROUND: Liver transplantation is the only life-saving therapeutic option for end-stage liver disease. Progressive donor organ shortage and declining donor organ quality justify the evaluation of the leverage of the Donor-Risk-Index, which was recently adjusted to the Eurotransplant community's requirements (ET-DRI). We analysed the prognostic value of the ET-DRI for the prediction of outcome after liver transplantation in our center within the Eurotransplant community. RESULTS: 291 consecutive adult liver transplants were analysed in a single centre study with ongoing data collection. Determination of the area under the receiver operating characteristic curve (AUROC) was performed to calculate the sensitivity, specificity, and overall correctness of the Eurotransplant-Donor-Risk-Index (ET-DRI) for the prediction of 3-month and 1-year mortality, as well as 3-month and 1-year graft survival. Cut-off values were determined with the best Youden-index. The ET-DRI is unable to predict 3-month mortality (AUROC: 0.477) and 3-month graft survival (AUROC: 0.524) with acceptable sensitivity, specificity and overall correctness (54% and 56.3%, respectively). Logistic regression confirmed this finding (p = 0.573 and p = 0.163, respectively). Determined cut-off values of the ET-DRI for these predictions had no significant influence on long-term patient and graft survival (p = 0.230 and p = 0.083, respectively; Kaplan-Meier analysis with Log-Rank test). CONCLUSIONS: The ET-DRI should not be used for donor organ allocation policies without further evaluation, e.g. in combination with relevant recipient variables. Robust and objective prognostic scores for donor organ allocation purposes are desperately needed to balance equity and utility in donor organ allocation.

Long-term outcome analysis of liver transplantation for severe hepatic trauma.

BACKGROUND: Liver transplantation (LTX) for severe hepatic trauma and its sequelae is a rare but potentially lifesaving option at the far end of the operative spectrum. METHODS: This study analyzes 12 cases with LTX for hepatic trauma and its consequences from two transplant centers. A total of 2,701 consecutive liver transplants unrelated to trauma served as a control group. χ and Mann-Whitney U-tests, Kaplan-Meier analysis with log-rank tests, and Cox regression analysis were applied. Addressed were issues before, during, and after LTX. Major study end points were patient and graft survival. RESULTS: The posttrauma transplant recipients are significantly younger (p = 0.014), with a significantly shorter graft survival (p = 0.038), resulting in a significantly higher retransplantation rate (p = 0.043). Of the 12 patients, 11 underwent surgical treatment for hepatic trauma before LTX with 7 of 12 patients experiencing liver necrosis at the time of LTX. Short-term survival and long-term survival are not significantly different between trauma and nontrauma patients. Severity of liver trauma (Moore Score) and concomitant injuries (Injury Severity Score [ISS]) have no significant impact on patient and graft survival. Four patients with hepatic trauma were treated with two-stage LTX with anhepatic phases between 14 hours and 28 hours. Two of those patients reached long-term survival (20-22 years). CONCLUSION: LTX for severe liver trauma and its consequences seems justified in extreme cases. The high frequency of liver necrosis at the time of LTX may indicate possible shortcomings in liver packing technique or liver resection for hemorrhage control. Thus, severe hepatic trauma requires treatment by experienced liver surgeons and emergency physicians. LEVEL OF EVIDENCE: Therapeutic study, level IV.

The Donor-Risk-Index, ECD-Score and D-MELD-Score all fail to predict short-term outcome after liver transplantation with acceptable sensitivity and specificity.

BACKGROUND: Expansion of the donor pool by the use of grafts with extended donor criteria reduces waiting list mortality with an increased risk for graft and patient survival after liver transplantation. This study investigates the ability of the Donor-Risk-Index (DRI), the Extended-Criteria-Donor-Score (ECD-score) and the D-MELD-score to predict early outcome after liver transplantation. MATERIAL/METHODS: 291 consecutive adult liver transplants (01.01.2007-31.12.2010) were analysed in a single centre study with ongoing data collection. Primary study endpoints were 30-day mortality, 3-month mortality, 3-month patient and graft survival and the necessity of acute retransplantation within 30 days. For the primary study endpoints ROC-curve analysis was performed to calculate the sensitivity, specificity, and overall model correctness of the Donor-Risk-Index (DRI), Extended-Criteria-Donor-Score (ECD-score) and the D-MELD-Score as predictive models. Cut-off values were selected with the best Youden index. RESULTS: ROC-curve analysis showed areas under the curve (AUROCs) <0.7 for the DRI, the ECD-Score and the D-MELD-Score as models for the prediction of 30-day mortality, 3-month mortality, 3-month patient survival, 3-month graft survival as well as the necessity of acute retransplantation within 30 days after transplantation with unacceptable low levels of overall model correctness (<62%) and specificity (<56%). CONCLUSIONS: The DRI, the ECD-Score and the D-MELD-Score all fail to predict short-term outcome after liver transplantation with acceptable overall model correctness in a current European transplant setting.

Value of the preoperative SOFT-score, P-SOFT-score, SALT-score and labMELD-score for the prediction of short-term patient and graft survival of high-risk liver transplant recipients with a pre-transplant labMELD-score ≥30.

BACKGROUND: The SOFT-score, P-SOFT-score, SALT-score and labMELD-score have been applied for the prediction of survival of liver transplant recipients after transplantation. We analysed the value of these scores for the prediction of short-term survival in high-risk liver transplant recipients with a labMELD-score ≥30. MATERIAL/METHODS: Retrospective single-centre analysis including 88 consecutive liver transplants in adults between 01.01.2007 and 31.12.2010 with a pretransplant labMELD-score ≥30 and follow-up until the 31.12.2011. Combined and living-related liver transplants were excluded. ROC-curve analysis was used to calculate sensitivity, specificity and overall model correctness of prognostic models. RESULTS: The P-SOFT-score demonstrated a significant influence on 1-year patient survival (p=0.045, Mann-Whitney-U test). Multivariate Cox regression analysis showed a significant influence of the P-SOFT-score on patient (p=0.013; Exp(B)=1.050; 95%CI: 1.010-1.091) and on graft survival (p=0.023; Exp(B)=1.042; 95%CI: 1.006-1.080). ROC-curve analysis showed areas under the curve (AUROCs) <0.5 for the SOFT-score, P-SOFT-score, SALT-score and the labMELD-score ≥30 for the prediction of 3-month patient and graft survival as well as 1-year patient and graft survival. CONCLUSIONS: Our results imply that the SOFT-score, P-SOFT-score, SALT-score and labMELD-score ≥30 all have a sensitivity, specificity and overall model correctness that is unable to discriminate short-term survivors from non-survivors in a collective of high-risk liver transplant recipients sufficiently in order to guide clinical decision making in the current German transplant situation with decreasing numbers of deceased liver donors, decreasing donor organ quality and increasingly sick transplant candidates.

Value of the SOFA score as a predictive model for short-term survival in high-risk liver transplant recipients with a pre-transplant labMELD score ≥ 30.

INTRODUCTION: The Sequential Organ Failure Assessment (SOFA) score has been applied for the prediction of survival in critically ill patients. We analysed the value of the SOFA score for the prediction of short-term survival after liver transplantation in high-risk liver transplant recipients with a labMELD score ≥30. PATIENTS AND METHODS: We conducted a retrospective single-centre analysis including 88 consecutive liver transplants in adults between January 1, 2007 and December 31, 2010 with a pre-transplant labMELD score ≥30. The SOFA score was assessed preoperatively, directly after transplantation and on post-operative days (PODs) 1-10. Combined and living-related liver transplants were excluded. Receiver operating characteristic (ROC) curve analysis with the Hosmer-Lemeshow test and application of the Brier score were used to calculate sensitivity, specificity, overall model correctness and calibration. Cutoff values were selected with the best Youden index. RESULTS: ROC curve analysis showed areas under the curve (AUROCs) >0.8 for the SOFA score on PODs 1-10 for the prediction of hospital mortality, 30-day mortality and 3-month mortality with Hosmer-Lemeshow test results that confirmed good model calibration (p > 0.05). The Brier score demonstrated an accuracy of prediction (<0.25) of hospital mortality, 30-day mortality and 3-month mortality for the SOFA scores on PODs 4-9 indicating superior accuracy on PODs 7 and 8 with cutoff values for the SOFA score between 16.5 and 18.5. The pre-transplant SOFA score failed to reach AUROCs >0.7 (0.603-0.663) for the prediction of short-term survival. CONCLUSIONS: Our results confirm the usefulness of the SOFA score in high-risk liver recipients during the early post-operative course, especially on PODs 7-8 for the prediction of hospital mortality, 30-day mortality and 3-month mortality and may be useful to predict futile early acute retransplantation.