National assessment of early biliary complications following liver transplantation: Incidence and outcomes

Abstract

Despite improved overall liver transplant outcomes, biliary complications remain a significant cause of morbidity. A national data set linking transplant registry and Medicare claims data for 17,012 liver transplant recipients was used to identify all recipients with a posttransplant biliary diagnosis code within the first 6 months after transplantation. Patients were further categorized as follows: a diagnosis without a procedure, a diagnosis and an associated radiological or endoscopic procedure, or a diagnosis treated with surgery. Overall, 15.0% had a biliary diagnosis, 11.2% required a procedure, and 2.2% had a surgical revision. Factors independently associated with biliary complications included donation after cardiac death (DCD), donor age, recipient age, split grafts, and long cold ischemia times. Graft loss was significantly more common for patients with biliary diagnoses [adjusted hazard ratio (aHR) = 1.89, confidence interval (CI) = 1.63‐2.19], interventions (aHR = 2.08, CI = 1.77‐2.44), and surgical procedures (aHR = 1.80, CI = 1.31‐2.49). Mortality after transplantation was also markedly increased for patients with biliary diagnoses (aHR = 2.18, CI = 1.97‐2.40), procedures (aHR = 2.21, CI = 1.99‐2.46), and surgeries (aHR = 1.77, CI = 1.41‐2.23). In stratified analyses, the impact of early biliary complications was greater for DCD liver recipients, but they remained highly significant for recipients of allografts from brain‐dead donors as well. Reducing biliary complications should improve posttransplant survival and reduce graft loss. Liver Transpl 20:446‐456, 2014. © 2014 AASLD.

Variation in Biliary Complication Rates Following Liver Transplantation: Implications for Cost and Outcome

“…While the use of health care claims limits the detailed analysis of care processes, these methods clearly identify patients with clinically significant biliary issues. Prior analyses using these methods, demonstrated that patients identified using a combination of diagnostic and procedure codes had over twice the rate of death and graft failure when compared with patients without BCs (21). These findings remain robust after adjustment for donor and recipient characteristics, as well as in stratified analysis considering DCD and DBD transplant separately.…”

“…In transplantation, this equation is made even more complex as a result of the substantial differences in donor quality and transplant factors such as cold ischemic times and choice of preservation solution (11,(15)(16)(17)(18)(19)21,25). In previous analyses, recipient factors including increased patient age, female gender, preoperative hyperbilirubinemia, retransplantation, smoking status, and socioeconomic status have all been found to increase the rate of a biliary leak, stricture or both.…”

“…Medicare billing claims include diagnostic and procedure codes as well as total payments for patients with Medicare fee for service primary or secondary insurance. Data linkage was performed as previously described (21,23). The cohort was restricted to patients noted to have Medicare as the primary insurer in the OPTN records at the time of transplantation with an appropriate charge for the transplant procedure.…”

“…Among these events, the development of biliary complications (BCs; leak, stricture and cholangitis) has been strongly associated with inferior clinical outcomes and increased health care spending in single center series, systematic reviews and database analyses (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21). However, the degree of variation in the incidence of BCs among transplant centers has never been rigorously studied, as BC data are not collected through clinical registries.…”

“…However, the degree of variation in the incidence of BCs among transplant centers has never been rigorously studied, as BC data are not collected through clinical registries. Large database studies are needed to assess the degree of center-level variation after controlling for previously identified donor and recipient factors that contribute to the development of these complications including the use of donation after cardiac death (DCD) donors (21).…”