The objective of this study was to determine the impact of pretransplant renal function on graft and patient survival rates after orthotopic liver transplantation (OLT) using the United Network for Organ Sharing (UNOS) database for adults who underwent OLT between 1988 and 1996. Based on calculated creatinine clearance (CCr) at the time of OLT, patients were classified arbitrarily into those with normal renal function (>70 mL/min) and mild (40-69.9 mL/min), moderate (20-39.9 mL/min), and severe (<20 mL/min) renal insufficiency. Of the 20,281 patients who underwent transplantation, complete data were available for 19,261 patients. Of these, 12,778 (67%) had normal CCr (mean, 118 ؎ 50 mL/min) and 4,419 (22%) had mild (56 ؎ 8.5 mL/min), 1,560 (8%) had moderate (30 ؎ 5.7 mL/min), and 504 (3%) had severe (14 ؎ 3.6 mL/min) renal failure. UNOS status 1 was more common in patients with moderate and severe renal failure. Primary graft nonfunction and 30-day mortality rates were higher and 1-, 2-, and 5-year graft and patient survival rates were lower in patients with moderate or severe renal failure. Multiple regression analysis showed that renal failure was an independent predictor of 30-day and 2-year mortality after adjusting for the recipient's age, sex, etiology of liver disease, diabetes status, body mass index, cold ischemic time, and UNOS status. CCr less than 40 mL/min was associated with significantly lower short-term and long-term graft and patient survival rates. In conclusion, our findings suggest that when Mayo End-Stage Liver Disease (MELD) score is used to prioritize organ allocation, lower-than-expected graft and patient survival rates may be seen. L iver transplantation has been the most important development in the management of end-stage liver disease in the past 2 decades. The immediate outcome of orthotopic liver transplantation (OLT) is dependent on many factors, including pretransplant serum creatinine levels. Renal insufficiency is common in patients before and after liver transplantation. The prevalence of renal impairment in patients undergoing OLT varies from 10% to 20%. 1-3 Although many of these patients may have hepatorenal syndrome (HRS), a potentially reversible condition, it is often difficult to make a firm diagnosis of HRS in patients with terminal liver disease. 4 Approximately 25% of liver transplantations are complicated by renal failure in the immediate postoperative period. [5][6][7][8] In addition, use of immunosuppressants such as cyclosporine and tacrolimus may cause further deterioration in renal function in this population. [7][8][9][10] Preoperative serum creatinine levels have been shown to be an important predictor of postoperative sepsis, 11,12 number of days spent in the intensive care unit, 3,13 need for preoperative and postoperative dialysis, 2,13 overall cost of liver transplantation, 13,14 and short-term graft and patient survival rates. 1,7,8,11,12,15 In one study, 2-year patient and graft survival rates were found to be similar in 31 patients with HRS and 263 with...

Studies assessing morbidity and mortality in obese patients undergoing orthotopic liver transplantation (OLT) have produced conflicting results, mainly because of the small sample size. The objective of our study was to determine graft and patient survival in obese adults receiving OLT in the U.S. between 1988 through 1996 using the United Network for Organ Sharing (UNOS) database. Among the 23,675 transplantations performed during the 9-year study period, 18,172 (75%) patients fulfilled the inclusion criteria. Of these, 8,382 (46%) were nonobese (body mass index [BMI] < 25 kg/m 2 ), 5,913 (33%) were overweight (BMI, 25.1-30 kg/m 2 ), 2,611 (14%) were obese (BMI, 30.1-35 kg/m 2 ), 911 (5%) were severely obese (BMI, 35.1-40 kg/m 2 ), and 355 (2%) were morbidly obese (BMI, 40.1-50 kg/m 2 ). The outcome measures assessed were immediate (30-day), 1-, 2-, and 5-year patient survival. Obese groups had a higher proportion of women, a greater prevalence of cryptogenic cirrhosis (P < .05) and diabetes (P < .05), and a higher serum creatinine. Primary graft nonfunction, and immediate, 1-year, and 2-year mortality were significantly higher in the morbidly obese group (P < .05). Five-year mortality was significantly higher both in the severely and morbidly obese subjects (P < .05), mostly as a result of adverse cardiovascular events. Kaplan-Meier survival was significantly lower in morbidly obese patients, and morbid obesity was an independent predictor of mortality. Obesity is associated with a significant increase in long-term mortality, mostly as a result of cardiovascular events. O besity is perhaps the most significant public health problem facing the United States today. 1 The National Health and Nutrition Examination Surveys (NHANES) show that there has been a significant increase in the prevalence of obesity between 1976 through 1989 (NHANES II) and 1988 through 1994 (NHANES III). 2 In NHANES III, 22.5% of all adults aged between 20 to 74 years had a body mass index (BMI) of more than 30 kg/m 2 . This increase was seen in men and women of all ages and all racial and ethnic groups.Perioperative morbidity and mortality are increased in obese patients after major surgical procedures because of concomitant problems such as coronary artery disease, hyperlipidemia, and restrictive pulmonary function. 1,3 There are only limited data on the effect of obesity on the outcome after transplantation. It has been shown that obese renal-transplant recipients have comparatively poorer graft and patient survival and a higher rate of wound infection compared with nonobese recipients. [5][6][7] In one study, actuarial patient and graft survival were not different in obese and nonobese patients undergoing renal transplantation, though the former had an increased incidence of wound infection and weight gain during the first year following transplantation. 4 There are few studies that had analyzed the impact of obesity on orthotopic liver transplantation (OLT). [8][9][10][11] In one study, Braunfeld et al. reported similar incidence of m...

The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the ‘Grading of Recommendations Assessment, Development and Evaluation (GRADE)’ system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years’ time.