Poor survival after liver retransplantation: Is hepatitis C to blame?

Abstract

Data from 1990 to 1996 suggest that the prevalence of hepatitis C virus (HCV) infection in repeated orthotopic liver transplantation (re-OLT) is increasing, and patient survival may be worse. Aims of the study are to: (1) assess the prevalence of HCV in re-OLT, (2) compare survival between primary OLT and re-OLT for HCV versus non-HCV diseases, and (3) evaluate Model for End-Stage Liver Disease (MELD) scores in re-OLT. The United Network for Organ Sharing database for adult patients undergoing primary OLT or re-OLT from January 1996 to June 2002 was analyzed. Patients with malignancy or those who underwent re-OLT within 30 days of primary OLT were excluded. A total of 22,120 primary OLTs and 2,129 reOLTs were performed. HCV was noted in 9,564 primary OLTs (43.2%) and 899 re-OLTs (42.2%). Overall 1, 3, and 5-year patient survival rates were 86%, 79%, and 73% for primary OLT, but 67%, 56%, and 52% for re-OLT (P < .001). Survival rates of patients with HCV at 1, 3, and 5 years were 86%, 76%, and 68% for primary OLT and 61%, 50%, and 45% for re-OLT (P < .001). Survival was less for patients with HCV compared with those with autoimmune hepatitis (AIH) and hepatitis B for re-OLT (P < .01). However, survival after re-OLT was no different for those with HCV than for those with all other causes. MELD scores between 11 and 20 were the most common for re-OLT. A marked decreased in survival was noted in all patients who underwent re-OLT with MELD scores greater than 25. HCV prevalence in OLT has reached a plateau in recent years. Survival after re-OLT is inferior to that for primary OLT, but re-OLT survival appears to have improved. Survival after re-OLT is lower in patients with HCV compared with those with AIH and hepatitis B, but no different than for those with most other liver diseases. Survival appeared worse in patients who underwent re-OLT with a MELD score greater than 25. (Liver Transpl 2003;9:1019-1024.) R ecurrence of hepatitis C virus (HCV) after orthotopic liver transplantation (OLT) is almost universal. [1][2][3][4] Recent data suggest that in approximately 20% of HCV-related transplantations, allograft cirrhosis develops within 5 years. 5-9 HCV-related re-OLT increased significantly throughout the early 1990s, 10 but there are no recent prevalence data to show if this trend continues.Patient survival after primary OLT for HCV infection throughout the 1990s was similar to that for most other indications for OLT. [11][12][13] However, a recent study by Forman et al 14 showed an increased rate of death and allograft failure in HCV-positive compared with HCV-negative transplant recipients. 14 In general, re-OLT has a lower survival rate than primary OLT. [15][16][17] In small studies, patient survival after re-OLT for HCV was not different compared with re-OLT for other causes. 1,3,12,18 Conversely, several other studies suggested that survival after re-OLT for HCV is significantly worse than that for non-HCV-related indications. 10,[19][20][21] These studies also suggested that survival is worse in patients wit...

Retransplantation for hepatitis C: Results of a U.S. multicenter retransplant study

“…18,[21][22][23] The reported ability of MELD scores to predict post-reTX survival has been variable. 9,[24][25][26][27] In our study, although MELD scores were not predictive of post-reTX survival, higher MELD scores (particularly Ͼ25) at the time of reTX were associated with high post-reTX mortality. Overall post-reTX patient survival at 3 yr was 40 to 56% for patients with HCV infection regardless of MELD scores, whereas in non-HCV patients, the survival at 3 yr was below 60% only when the MELD score was above 30 (survival was 37%).…”

“…As expected, MELD score increased at each interval of evaluation from initial transplantation to reTX. At the time of the first listing and transplantation the MELD scores were higher in group 2 and 3 compared to group 1 (first listing, mean MELD score, 13 [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] vs. 18 vs. 15 ; first transplant, mean MELD score, 15 vs. 20 vs. 18 ). MELD scores at second listing and reTX were distinctly higher than initial listing and transplantation (second listing, mean MELD score, 21 vs. 21 vs. 25 ; reTX, mean MELD score, 26 vs. 25 ).…”

“…6,9,10,14 The advantage of this study was that the pathological confirmation of graft failure was available, which is not available in large database resources. Several single-center studies have noted slightly higher survival than reported by our group.…”

“…The length of stay was about 1 week longer at reTX (second transplant, median days Ϯ standard deviation, 13 Ϯ 4 vs. 19 Ϯ 3 ). Interestingly, ICU days were similar among groups and transplants (first transplant, median days, 2 Ϯ 0.5 vs. 3 Ϯ 0.5 [1][2][3][4][5][6][7][8][9][10]; second transplant, median days 3 Ϯ 2 [1-70] in both groups). In group 1, 21 (49%) patients were hospitalized at the time of reTX and 4 (9%) were in the ICU.…”

“…[6][7][8][9][10][11][12][13][14][15][16][17][18] Utilizing the United Network for Organ Sharing registry, Rosen and Martin 6 showed worse outcome in patients retransplanted for HCV from 1990 to 1996. In contrast, Watt et al 9 reported similar patient survival in HCV compared to other etiologies, but showed progressively decreased survival as the Model for End-Stage Liver Disease (MELD) score increased, especially when it was greater than 25. While analysis of the United Network for Organ Sharing or Scientific Registry of Transplant Recipients database is helpful, detailed information (e.g., histopathology) concerning the cause of graft failure is lacking.…”