Assessing Risk in Liver Transplantation

Doyle, Howard R.; Marino, Ignazio R.; Morelli, F.; Doria, Cataldo; Aldrighetti, Luca; McMichael, John; Martell, Joan; Gayowski, Timothy; Starzl, Thomas E.

doi:10.1097/00000658-199608000-00009

Cited by 76 publications

(20 citation statements)

References 43 publications

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“…15,16,22 Preoperative recipient physiology, reflected in our model by recipient age, creatinine, PT, and bilirubin, has been well established as an independent risk of death. 15,17,21,22,26 In addition to recipient factors, our model also includes an assessment of the donor organ, as indicated by donor age, which has been clearly demonstrated to be a primary determinant of graft function. 20,27 Perioperative events that influence patient sur- vival are reflected in the model by warm and cold ischemia times.…”

Section: Discussionmentioning

confidence: 99%

Pretransplant Model to Predict Posttransplant Survival in Liver Transplant Patients

Ghobrial¹,

Gornbein²,

Steadman³

et al. 2002

Annals of Surgery

149

138

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ObjectiveTo develop a prognostic model that determines patient survival outcomes after orthotopic liver transplantation (OLT) using readily available pretransplant variables. Summary Background DataThe current liver organ allocation system strongly favors organ distribution to critically ill recipients who exhibit poor survival outcomes following OLT. A severely limited organ resource, increasing waiting list deaths, and rising numbers of critically ill recipients mandate an organ allocation system that balances disease severity with survival outcomes. Such goals can be realized only through the development of prognostic models that predict survival following OLT. MethodsVariables that may affect patient survival following OLT were analyzed in hepatitis C (HCV) recipients at the authors' center, since HCV is the most common indication for OLT. The resulting patient survival model was examined and refined in HCV and non-HCV patients in the United Network for Organ Sharing (UNOS) database. Kaplan-Meier methods, univariate comparisons, and multivariate Cox proportional hazard regression were employed for analyses. ResultsVariables identified by multivariate analysis as independent predictors for patient survival following primary transplantation of adult HCV recipients in the last 10 years at the authors' center were entered into a prognostic survival model to predict patient survival. Accordingly, mortality was predicted by 0.0293 (recipient age) ϩ 1.085 (log 10 recipient creatinine) ϩ 0.289 (donor female gender) ϩ 0.675 urgent UNOS -1.612 (log 10 recipient creatinine times urgent UNOS). The above variables, in addition to donor age, total bilirubin, prothrombin time (PT), retransplantation, and warm and cold ischemia times, were applied to the UNOS database. Of the 46,942 patients transplanted over the last 10 years, 25,772 patients had complete data sets. An eight-factor model that accurately predicted survival was derived. Accordingly, the mortality index posttransplantation ϭ 0.0084 donor age ϩ 0.019 recipient age ϩ 0.816 log creatinine ϩ 0.0044 warm ischemia (in minutes) ϩ 0.659 (if second transplant) ϩ 0.10 log bilirubin ϩ 0.0087 PT ϩ 0.01 cold ischemia (in hours). Thus, this model is applicable to first or second liver transplants. Patient survival rates based on model-predicted risk scores for death and observed posttransplant survival rates were similar. Additionally, the model accurately predicted survival outcomes for HCV and non-HCV patients. ConclusionsPosttransplant patient survival can be accurately predicted based on eight straightforward factors. The balanced application of a model for liver transplant survival estimate, in addition to disease severity, as estimated by the model for end-stage liver disease, would markedly improve survival outcomes and maximize patients' benefits following OLT.

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Section: Discussionmentioning

confidence: 99%

Pretransplant Model to Predict Posttransplant Survival in Liver Transplant Patients

Ghobrial¹,

Gornbein²,

Steadman³

et al. 2002

Annals of Surgery

149

138

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“…Overall, 14 patients received liver and kidney transplants over a period when 208 liver transplants were performed, reflecting a bias toward LKT when compared with 23 LKTs in a multicenter series of 805 consecutive primary liver transplants or 19 LKTs of 1520 liver transplants performed at Pittsburgh. 13,18 In contrast to our population, the multicenter data included 40 patients with fulminant hepatic failure, 16 of whom had renal insufficiency. Patient and graft survival were adversely affected in that series by renal insufficiency in the setting of fulminant hepatic failure or renal insufficiency requiring dialysis after liver transplantation.…”

Section: Discussionmentioning

confidence: 99%

“…11,12 However, a retrospective review of 1520 liver transplant recipients failed to show an association between a positive crossmatch and overall graft survival. 13 As a result, the protective role of the liver allograft remains controversial as well. Presently, the proper indications for LKT and the application of cross-matching to liver transplantation are in evolution.…”

mentioning

confidence: 99%

Combined liver-kidney transplantation in patients with cirrhosis and renal failure: Effect of a positive cross-match and benefits of combined transplantation

et al. 1998

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Patients with renal failure after liver transplantation have a particularly poor prognosis. Therefore, in the setting of end-stage renal disease requiring dialysis or severe renal insufficiency that will not improve after liver replacement, combined liver-kidney transplantation (LKT) is the preferred approach. We have adopted a policy of LKT in patients with end-stage liver disease and renal insufficiency undergoing dialysis or with a creatinine clearance less than 35 mL/min and evidence of chronic renal dysfunction. Since 1991, we have performed 208 orthotopic liver transplantations. Fourteen patients (8%) have undergone combined LKT, including 6 patients undergoing hemodialysis. Cytotoxic cross-matches (modified Amos technique and antihuman globulin method) were performed on 13 of 14 patients and were positive in 3 patients. Two patients died less than 4 months after LKT and 12 patients are alive and well. Graft survival censored for patient death was 100% for liver allografts and 93% for renal allografts, with a mean follow-up of 39 ؎ 24 months. The most recent serum creatinine level in the patients with the 11 functioning grafts was 1.1 ؎ 0.6 mg/dL. Biopsy-proven acute rejection occurred in 50% of simultaneous liver allografts. By contrast, only a single episode (6%) of renal allograft dysfunction was attributable to acute rejection. All rejection episodes occurred in the first 90 days after transplantation and were steroid sensitive. Three of 14 combined procedures were performed in the setting of a positive cytotoxic cross-match. In 2 recent patients, the results were confirmed by positive cross-matches to the donor's T and B cells by flow cytometry. Flow cytometric cross-matches reverted to negative 1 hour after liver transplantation and several hours before the administration of antithymocyte globulin. The cross-matches remained negative on postoperative days 1 and 7. Presently, all 3 patients with a positive cross-match enjoy normal hepatic and renal function at 631, 706, and 2275 days follow-up. Renal scans were performed in 4 LKT recipients not previously undergoing hemodialysis and indicated varying and unpredictable degrees of function in the native and transplanted kidneys. In conclusion, combined LKT can be performed safely and is associated with a low rate of acute rejection, even in the setting of a positive cross-match. Predicting which patients with renal insufficiency will benefit from LKT remains challenging; however, these results suggest that LKT should be encouraged in patients with evidence of irreversible renal insufficiency who require liver transplantation.

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“…Other reports indicated a higher incidence of vanishing bile duct syndrome [12], and more severe acute rejection episodes [13,14] or acute rejection within 3 months after transplantation [15] in cases with crossmatch-positive grafts. The adverse effects of a positive crossmatch on patient and graft survival are also emphasized in other reports [4,5,16,17,18,19,20,21], but the rate of hyperacute rejection or the causal association between graft loss and acute rejection is not clear.…”

Section: Introductionmentioning

confidence: 93%

Positive Lymphocytotoxic Crossmatch Does Not Adversely Affect Survival in Living Donor Liver Transplantation

Sugawara¹,

Tamura²,

Kaneko³

et al. 2009

Dig Surg

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Background/Aims: The influence of lymphocytotoxic crossmatch on survival or acute rejection in liver transplantation remains controversial. Data regarding graft survival and acute rejection of living donor liver transplantation (LDLT) are limited. Methods: We retrospectively examined the influence of a positive T or B lymphocytotoxic crossmatch on survival and acute rejection in patients using a database of 414 consecutive LDLT cases. Results: The rejection-free rate at 90 days after LDLT was lower in patients that were T crossmatch-positive compared to patients that were both T and B crossmatch-negative (52 vs. 74%, p = 0.03). No patients with a positive lymphocytotoxic crossmatch died due to immunologic causes. The crossmatch results had no effect on graft survival. Conclusion: In the positive crossmatch groups, there was no acute rejection that was untreatable or that caused graft loss. These findings indicate that a positive crossmatch graft should not be considered a contraindication for LDLT.

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Assessing Risk in Liver Transplantation

Abstract: The cytotoxic crossmatch is not statistically associated with overall graft survival after liver transplantation. However, early failure rates are higher in the positive crossmatch cases, a difference that disappears by the second year.

Cited by 76 publications

References 43 publications

Pretransplant Model to Predict Posttransplant Survival in Liver Transplant Patients

Pretransplant Model to Predict Posttransplant Survival in Liver Transplant Patients

Combined liver-kidney transplantation in patients with cirrhosis and renal failure: Effect of a positive cross-match and benefits of combined transplantation

Positive Lymphocytotoxic Crossmatch Does Not Adversely Affect Survival in Living Donor Liver Transplantation

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