Pretransplant echocardiographic parameters as markers of posttransplant outcomes in liver transplant recipients

Abstract

Despite advances in liver transplantation and preoperative risk stratification, there remains significant posttransplant morbidity and mortality from cardiovascular and renal disease. There are limited and conflicting data on the role of pretransplant echocardiography to predict these outcomes. The purpose of our study was to determine if pretransplant echocardiographic parameters were associated with posttransplant survival and the development of incident cardiovascular events and chronic kidney disease (CKD). We conducted a retrospective cohort study of 397 adult liver transplant recipients at the University of Pennsylvania from January 1, 2005 to September 30, 2014. Patients with acute liver failure, those without a diagnosis of cirrhosis (eg, polycystic liver disease without portal hypertension), retransplants, and multiorgan transplants were excluded. In multivariable Cox regression models, tricuspid regurgitation graded greater than mild was associated with significantly increased posttransplant mortality (hazard ratio, 1.68; 95% confidence interval [CI], 1.03-2.75; P 5 0.04). In multivariable competing risk models, increasing pulmonary artery systolic pressure (PASP) was associated with significantly increased risk of hospitalization for myocardial infarction or heart failure (subhazard ratio per 5 mm Hg increase in PASP, 1.79; 95% CI, 1.48-2.17; P < 0.001). In multivariable competing risk models, increased left ventricular ejection fraction (LVEF) was associated with a numerical but nonsignificant increased risk of stage 4 or 5 CKD (subhazard ratio, 1.11 per 5% increase in LVEF; 95% CI, 0.99-1.24; P 5 0.07). In a post hoc analysis, LVEF 65% was the best cutoff for increased risk of CKD (subhazard ratio, 1.75; 95% CI, 1.06-2.89; P 5 0.03). In conclusion, several pretransplant echocardiographic parameters were associated with posttransplant morbidity and mortality, suggesting that pretransplant echocardiography may be used as a tool to risk-stratify patients for posttransplant outcomes. Liver Transpl 22:316-323, 2016. V C 2015 AASLD.Received August 7, 2015; accepted November 24, 2015.Advances in liver transplantation and preoperative risk stratification have led to improved outcomes in liver transplant recipients over the past several decades. 1 Yet as patient survival has increased, cardiovascular and renal disease have been recognized as major causes of posttransplant morbidity and mortality. 2 These findings may in part be explained by exposure to immunosuppressive agents that lead directly to renal dysfunction 3 coincident to an increased prevalence of cardiovascular risk factors such as hypertension, diabetes, and hyperlipidemia in transplant recipients, 4 particularly in those with nonalcoholic steatohepatitis. However, the pretransplant circulatory changes resulting from portal hypertension are associated with cardiac

Systemic-to-pulmonary artery pressure ratio as a predictor of patient outcome following liver transplantation

“…A recent study from Bushyhead et al[16] investigated preoperative data of liver transplant recipients and found that the pulmonary artery systolic pressure correlates with posttransplant outcome and therefore emphasized the importance of right ventricular assessment and pulmonary vascular resistance for the morbidity and mortality associated with the procedure. However, the publication did not assess the value of the MAP/mPAP ratio for preoperative risk stratification.…”

Cardiac diseases among liver transplant candidates

“…Tricuspid regurgitation has been associated with worsening pulmonary hypertension in the general population . Greater‐than‐mild tricuspid regurgitation is associated with increased postoperative mortality rate and graft failure . Among LT candidates, moderate‐to‐severe tricuspid regurgitation can signify either severe fluid overload or decompensation of portopulmonary hypertension.…”

“…72 Greater-than-mild tricuspid regurgitation is associated with increased postoperative mortality rate and graft failure. 73 Among LT candidates, moderateto-severe tricuspid regurgitation can signify either severe fluid overload or decompensation of portopulmonary hypertension. Both can affect perioperative management and must be investigated and treated before LT.…”

Cardiovascular risk after orthotopic liver transplantation, a review of the literature and preliminary results of a prospective study

“…Bushyhead et al[88] tried to determine if specific findings in pre-transplant echocardiography were associated with post-transplant survival and the development of cardiovascular and renal disease. The results of this study showed that increasing pulmonary artery systolic pressure was associated with significantly increased risk of hospitalization for myocardial infarction or heart failure, while increased left ventricular ejection fraction, a possible expression of cirrhotic cardiomyopathy, was associated with a non-significant increased risk of stage 4 or 5 chronic kidney disease.…”