A Regional Experience With Emergency Liver Transplantation1

Abstract

Liver transplantation for patients requiring life-support results in the lowest survival and highest costs. A ten year (1983-1993) regional experience with liver transplantation for critically ill patients was undertaken to ascertain the fate of several subgroups of patients. Of the 828 liver transplants performed at six transplant centers within the region over this period, 168 (20%) were done in patients who met today's criteria for a United Network of Organ Sharing (UNOS) status 1 (emergency) liver transplant candidate. Recipients were classified according to chronicity of disease and transplant number (primary-acute, primary-chronic, reTx-acute, reTx-chronic). Overall one-year survival was 50% for all status 1 recipients. The primary-acute subgroup (n = 63) experienced a 57% one-year survival compared with 50% for the primary-chronic (n = 51) subgroup (P = 0.07). Of the reTx-acute recipients (n = 43), 44% were alive at one year in comparison with 20% for the reTx-chronic (n = 11) group (P = 0.18). There was no significant difference in survival for the following: transplant center, blood group compatibility with donors, age, preservation solution, or graft size. For patients retransplanted for acute reasons (primary graft nonfunction (PGNF) or hepatic artery thrombosis [HAT]), survival was significantly better if a second donor was found within 3 days of relisting (52% vs. 20%; P = 0.012). Over the study period progressively fewer donor organs came from outside the region. No strong survival-based argument can be made for separating, in allocation priority, acute and chronic disease patients facing the first transplant as a status 1 recipient. Clearly patients suffering from PGNF or HAT do far better if retransplanted within 3 days. Establishing an even higher status for recipients with PGNF, perhaps drawing from a supraregional donor pool, would allow surgeons to accept more marginal donors, thus potentially expanding the pool, without significantly compromising patient survival. Retransplantation of the recipient with a chronically failing graft who deteriorates to the point of needing life-support is nearly futile, and in today's health care climate, not an optimal use of scarce donor livers.

Liver retransplantation for primary nonfunction: Analysis of a 20-year single-center experience

“…It can be argued whether it is worthwhile to proceed with retransplant or if retransplant should be avoided when the chance of survival is low,33–35 because it is well known that the sickest patients and retransplanted patients have the lowest survival rates and the highest hospital charges 36–37. PNF had incidences of complications as high as or higher than retransplants for other causes (Tables 2 and 3).…”

Morphometric analysis of primary graft non‐function in liver transplantation

“…Controversial aspects are the role of donor age and the length of the period of intensive care on the outcome of the patient. In this respect, studies have found no significant correlation with the recipient/graft outcome 29,30 although some authors have found an initial decay of function in grafts originating from aged donors 31,32 …”

Using Root Cause Analysis to Improve Survival in a Liver Transplant Program1

“…These concerns were explored further to learn why those particular root causes had continued to occur (Step 7). The teams then developed risk-reduction strategies for our care process system-usually protocol changes-which our program instituted to improve our quality of care (Step 8; Table 7) [42][43][44][45][46][47].…”