Is liver transplantation ‘out-of-hours’ non-inferior to ‘in-hours’ transplantation? A retrospective analysis of the UK Transplant Registry

Abstract

ObjectivesIncreased morbidity and mortality have been associated with weekend and night-time clinical activity. We sought to compare the outcomes of liver transplantation (LT) between weekdays and weekends or night-time and day-time to determine if ‘out-of-hours’ LT has acceptable results compared with ‘in-hours’.Design, setting and participantsWe conducted a retrospective analysis of patient outcomes for all 8816 adult, liver-only transplants (2000–2014) from the UK Transplant Registry.Outcome measuresOutcome measures were graft failure (loss of the graft with or without death) and transplant failure (either graft failure or death with a functioning graft) at 30 days, 1 year and 3 years post-transplantation. The association of these outcomes with weekend versus weekday and day versus night transplantation were explored, following the construction of a risk-adjusted Cox regression model.ResultsSimilar patient and donor characteristics were observed between weekend and weekday transplantation. Unadjusted graft failure estimates were 5.7% at 30 days, 10.4% at 1 year and 14.6% at 3 years; transplant failure estimates were 7.9%, 15.3% and 21.3% respectively.A risk-adjusted Cox regression model demonstrated a significantly lower adjusted HR (95% CI) of transplant failure for weekend transplant of 0.77 (0.66 to 0.91) within 30 days, 0.86 (0.77 to 0.97) within 1 year, 0.89 (0.81 to 0.99) within 3 years and for graft failure of 0.81 (0.67 to 0.97) within 30 days. For patients without transplant failure within 30 days, there was no weekend effect on transplant failure. Neither night-time procurement nor transplantation were associated with an increased hazard of transplant or graft failure.ConclusionsWeekend and night-time LT outcomes were non-inferior to weekday or day-time transplantation, and we observed a possible small beneficial effect of weekend transplantation. The structure of LT services in the UK delivers acceptable outcomes ‘out-of-hours’ and may offer wider lessons for weekend working structures.

Evaluation of the Nighttime Operation Impact on Liver Transplantation: A Meta-Analysis

“…In term of the significant result reported, one possible explanation for this discrepancy would be they were from single-center reports with limited center experience and center volume [11,17]. In contrast, large studies using United Network for Organ Sharing (UNOS) database or the UK Transplant Registry Database showed that patient survival after liver transplantation was not influenced by nighttime surgery [10,12,13]. In other organ transplants, such thoracic organ, studies based on UNOS also demonstrated no difference between nighttime and daytime procedure on the results of patients' survival [26].…”

“…Furthermore, overnight procedure allows more concentration and less distraction from outside environment [29]. These might be the possible explanations why some studies found less technical failure off regular work time [10,30].…”

“…After thorough consideration, it is not difficult to argue that the core for this issue is not the time point itself but the availability of adequately trained, fully physiological prepared surgeons and support team during nighttime procedure. Although the seniority of transplantation team (surgeons, anesthesiologists, nurses and intensive care staff) could not be quantitatively collected, many studies emphasized the importance of highly experienced transplant team and specialized over-night on call schedule [17,9,10,12,13]. Too much workload within a short period of time would definitely degrade operation quality and increase the postoperative complication risk.…”

“…Then, full text was assessed to identify the eligible studies. At last, 6 studies met all the criteria and were included [9][10][11][12][13]17]. Among them, three studies were performed in the USA, two studies were in the Europe and one study was conducted in China.…”

“…The result of three studies was from single-center investigations [9,11,17]. The other three studies were multi-center results by using either the United Network for Organ Sharing database (UNOS) in the USA or the UK Transplant Registry database [10,12,13]. The detailed overview of each study was in Table 1.…”