How Can We Improve the Selection of Patients Awaiting Liver Retransplantation?

OBJECTIVE: To analyze predictors of survival involved in liver retransplantation (LRT), including the Rosen Model (RM). MATERIALS AND METHODS: This was a descriptive, observational, and unicentric study based on predictors of survival including patients who underwent LRT in a tertiary medical center between April 2002 and December 2018. Recipient, donor, and transplant data were collected, and RM score was calculated for every patient. Fisher exact test and Student t test were used for qualitative and quantitative variables, respectively. The Shapiro-Wilks test was applied to verify the normality of the sample. Survival differences between subgroups were checked using the log-rank test. Statistical significance was stated at P < .05. RESULTS: Among 32 retransplanted patients in this period, 17 (53.1%) survived more than 12 months after LRT. The results of statistical associations between prognostic factors and overall survival highlighted that an older recipient age was significantly correlated with a lower overall survival. The 3-month overall survival was 84.3%. Nineteen patients had a low risk according to RM, with a 3-month survival rate of 78.9%. Eight had a RM intermediate risk, with a survival rate of 21%. Despite the aforementioned data, the log-rank test did not find statistical differences in survival (P = .488). CONCLUSION: We should consider older recipient age as a negative prognostic factor of overall survival. Also, we should contemplate intermediate risk according to RM as an adverse predictor regarding survival in LRT. Both data are of interest regarding the indication or not of LRT and prioritization on the waiting list.

Liver Transplantation in Recipients With High Model for End-stage Liver Disease Score.

OBJECTIVES: The score in the Model of End-stage Liver Disease, or MELD, is a good indicator of the survival in patients on the liver transplant waiting list. In this study, an analysis is performed on the benefits of liver transplant on those patients with a very high MELD score and who thus start from a very severe baseline state that could affect the surgical outcome. MATERIALS AND METHODS: A prospective study was conducted on a cohort of 331 patients that received a liver transplant between 2002 and 2014. The patients were divided into 2 groups according to the MELD score (<28 vs ≥28), and differences in age, postoperative complications, stay in the intensive care unit (ICU), hospital stay, and survival were compared. RESULTS: Of the total of 331 patients, 21 (6.3%) had a MELD score ≥ 28. The mean age of the group with MELD score ≥ 28 was lower than the age in the group with MEDL score < 28 (42.5 vs 53.7 years; P < .0001). No significant increase was observed in postoperative complications. Although there were also no differences in survival, the group with MELD score ≥ 28 did have a longer stay in ICU and a longer hospital stay (with a mean of 6.7 days in ICU and 41.5 days admission vs 4.1 and 26.9, respectively). CONCLUSIONS: A very high MELD score is associated with a longer stay in ICU and more days of hospital admission, although no differences were observed in postoperative complications or survival. Therefore, there does not seem to be any contraindication in transplantation in this group of patients.

Analysis of Indications and Results in Liver Retransplantation: Is Late Retransplantation Worthwhile?

BACKGROUND: Liver retransplantation (LrT) is the only therapeutic option for irreversible hepatic graft failure. Despite various improvements, its technical complexity entails a greater morbidity in the short and long term. The main goal of the study was to analyze the activity of LrT at our center, as well as its indications, timing, postoperative evolution, and the long-term survival of patients. METHODS: We designed a descriptive study of a cohort of patients who underwent LrT in a Spanish Hepatic Transplant Unit, between April 1, 2002 and December 31, 2015. RESULTS: A total of 366 primary orthotopic liver transplantations were performed, 20 of which were LrTs, resulting in a 5.5% retransplantation rate. The most frequent indication for LrT was hepatic artery thrombosis (HAT) (35%). Twenty-five percent of the LrTs were early retransplantations and 75% were late retransplantations. After LrT, 35% of the grafts showed liver dysfunction. The overall mortality rate was 45%: in early LrT this was 25% and in late LrT it was 46.7%. Graft actuarial survival at 1 month post-LrT was 75% and at 5 years it was 63.6%. The overall actuarial survival after LrT at month 1, year 1, year 3, and year 5 was 80%, 69.6%, 58.9%, and 50.5%, respectively. In the late LrT group, the results proved less favorable, so it is necessary to define the minimum acceptable result before proceeding to a second graft. CONCLUSION: Our LrT rate was lower than that reported by other groups in our country. The actuarial survival rates for graft and patient are comparable to those obtained by other groups.

Analysis of the Predictive Ability for Graft Loss and Mortality of Two Criteria for Early Allograft Dysfunction After Liver Transplantation.

INTRODUCTION: The current imbalance between available donors and potential recipients for orthotopic liver transplantation (OLT) has led to a liberalization of organ acceptance criteria, increasing the risk of post-transplant complications such as early allograft dysfunction (EAD). Consequently, we need accurate criteria to detect patients with early poor graft function to guide the strategies of management. We evaluated the usefulness of two frequently used criteria: the definition from Olthoff et al and the Model for Early Allograft Function (MEAF) scoring. PATIENTS AND METHODS: Unicentric cohort study of patients undergoing OLT between January 1, 2010, and November 20, 2016. We performed a univariate study to detect donor, recipient, and transplant factors favoring EAD, defined both by Olthoff criteria and a MEAF score higher than 7. Finally, we developed a comparative survival analysis for cases having or not EAD. RESULTS: In all, 201 transplants met inclusion criteria. According to the stated cutoff for MEAF score, the frequency of EAD was 9.3%, with a significant association to low recipient body mass index and prolonged total graft ischemia time, resulting in lower patient 3-month postoperative survival. According to Olthoff criteria, EAD incidence was 22.1% and was associated with younger donor and recipient ages and higher Model for End-stage Liver Disease and Child-Pugh recipient scores. Its development resulted in lower graft and recipient survival at 3 months after OLT. CONCLUSION: MEAF score and Olthoff criteria are useful tools for detection of EAD. The latter could select more appropriately patients at risk, but its calculation cannot be done until the seventh day after OLT, unlike MEAF score, available on third day.

Influence of Obesity on Liver Transplantation Outcomes.

OBJECTIVE: The aim of this work was to determine the impact of obesity on the morbidity and mortality of liver transplantation (LT) recipients. METHODS: A single-center, observational-cohort, retrospective study was conducted in patients undergoing LT from January 2008 to December 2014 to compare complications and survival between those with body mass index (BMI) <35 kg/m2 and those with BMI ≥35 kg/m2. RESULTS: The study included 170 patients: 162 (95.3%) with BMI <35 kg/m2 and 8 (4.7%) with BMI ≥35 kg/m2. The groups significantly differed in overall mortality and graft survival: The risk of death was 3.54-fold higher (95% confidence interval, 1.39-9.03) and the mean graft survival was shorter (61 vs 21 mo; P = .001) in the group with BMI ≥35 kg/m2. The groups did not significantly differ in rates of biliary complications, arterial and portal vein thrombosis, retransplantation or reintervention, intraoperative requirement for blood products, length of intensive care unit stay, or post-reperfusion syndrome or rejection rates. CONCLUSIONS: Although no significant differences were found between these groups in post-transplantation complications, BMI ≥35 kg/m2 emerged as a mortality risk factor in these patients.