Sunday Poster Sessions,
Topic:
Liver Transplantation
Background:
Current guidelines for treatment of chronic HCV utilize EVR
to indicate which patients are likely to achieve an SVR. Reports show a 72% SVR
rate in patients with an EVR. The purpose of this study was to evaluate the
week 12 viral response on SVR rate in chronic HCV post liver transplant
patients.
Methods:
This is a secondary analysis of a multi-center randomized
clinical trial of post OLT patients with recurrent HCV treated with 2 dosages
of PEG IFN alfa-2b plus ribavirin 800 mg/day. PEG IFN dosage began at 0.5 mcg/kg/wk and increased in the high dose group to 1.5
mcg/kg/wk over 6 weeks.
Results:
The total sample contained 59 patients (27 low dose and 32 on
high dose treatment). There were 39 males and 20 females ranging from 37 to 67
years of age (mean 51.4 ± 6.0). Race distribution was White 45 (76%), Black 3
(5%), Hispanic 10 (17%) and Asian 1 (2%). At treatment week 12, 32 (54%)
patients achieved undetectable HCV RNA, 4 (7%) patients had ≥2 log
decrease with positive virus, and 23 (39%) patients had <2 log decrease
(Table 1). There was higher SVR rate in the undetectable virus group at week 12
(23/32, 72%) compared to patients with positive virus and ≥2 log decrease
(1/4, 25%) or <2 log decrease (0/23, 0%). SVR rate was notably higher in
genotype 1 patients with week 12 undetectable virus vs. those with detectable
virus, 13/19 (68%) vs. 0/25 respectively (p=0.001). In genotype 2/3 patients,
SVR was achieved by 10/13 (77%) with week 12 undetectable virus vs. 1/2 (50%)
with detectable virus (p=0.2). 1 patient, a male with genotype 3, stage 1
fibrosis on high dose therapy with detectable virus at week 12, achieved an
SVR.
Conclusions:
·
Slow
viral responders in the post-transplant population, within a ≥ 2 log
decrease but positive virus a week 12, have a significantly reduced chance of
SVR with the standard 48 weeks of treatment than those with undetectable virus
at week 12.
·
Further
investigation is needed to improve SVR rates for slow viral responding
patients.
Number of Patients with Undetectable HCV RNA
|
PEG IFN
Group |
Week 12
Viral Response |
n |
Week 24 |
Week 48 |
SVR |
p Value |
|
Low Dose |
<2 log decrease |
19 |
1 (5%) |
1 (100%) |
0 (0%) |
0.001 |
|
≥2 log decrease but positive |
2 |
0 (0%) |
0 (0%) |
0 (0%) |
||
|
Virus undetectable |
6 |
6 (100%)* |
5 (83%) |
5 (83%) |
||
|
High Dose |
<2 log decrease |
1 |
0 (0%) |
0 (0%) |
0 (0%) |
|
|
≥2 log decrease but positive |
5 |
1 (20%) |
1(20%) |
1 (20%) |
||
|
Virus undetectable |
26 |
26 (100%* |
21 (81%)** |
19 (73%) |
*1 genotype 2/3
patient in each PEG dosing group discontinued at week 24 and subsequently relapsed
**5 patients discontinued prior to week 48 with side effects
521. Chronic
hepatitis E : a new entity
in organ transplant patients
N. Kamar; J. Péron; L. Ouezzani; J. Mansuy; J. Selves;
C. Bureau; J. Guittard; J. Izopet; D. Durand; J. Vinel; L. Rostaing
Introduction:
Hepatitis E virus (HEV) is a RNA virus that causes acute
hepatitis in developing countries, but also sporadic cases in industrialized
countries (non travel associated or autochthonous hepatitis E). Non travel
associated hepatitis E have a predilection for middle aged and elderly males,
are caused by genotype 3 and can carry significant morbidity especially when
seen in the context of chronic liver disease. We describe for the first time a
chronic evolution in organ transplant patients.
Patients:
We identified 14 cases of hepatitis E infection in
Conclusion:
- In organ-transplant patients, HEV should be considered an etiological agent for hepatitis E (HCV RNA in serum and the stools).
- For the first time, we have shown that HEV infection can involve to chronic hepatitis at least in organ-transplant patients.
- A longer follow-up is required to assess the outcome of HEV infection in the setting of organ-transplant receipents.
522.
Post-Liver Transplant Survival in Hepatitis C Patients is Improving, Not
Declining.
J. G. O'Leary; L. M. Grant; H. Randall; N. Onaca; L.
Jennings; G. Klintmalm; G. L. Davis
Introduction:
Outcomes after orthotopic liver transplant (OLT) for chronic
hepatitis C (HCV) have been reported to be worsening over the last 2 decades.
We analyzed our center’s experience over 15 years to identify trends in
post-OLT survival in patients with and without HCV.
Methods:
Patient and graft survival of adult primary OLT recipients
from January 1991 to June 2006 at Baylor Regional Transplant Institute (n=2051)
were evaluated by Kaplan-Meyer analysis.
Those with or without HCV were analyzed by era:
·
Era
1:1991-1994 (n=509),
·
Era
2:1995-1998 (n=459),
·
Era
3:1999-2002 (n=532), and
·
4:2003-6/2006
(n=551).
Differences in eras with disparate survivals were assessed by
univariate and multivariate analysis.
Results:
Overall, patient and graft survival were significantly lower
among HCV recipients than in others (p<0.0001). This difference was
dependent on the era of transplantation with improvement in HCV patient
(p=0.0015) and graft (p<0.0001) survival in sequential eras: 5-year patient
survival of 61.5%, 62.6%, and 75.6% for eras 1, 2, and 3, respectively (era 4 not
evaluable yet). The change is largely related to changes in listing criteria
for hepatocellular carcinoma (HCC) beginning in era 3. Survival in those
transplanted for HCV with HCC has improved dramatically over time
(p<0.0001). In fact, there was no change in post-OLT patient survival over
time (p=0.19) when those with HCC were excluded from the HCV cohort, while
graft survival still improved in successive eras (p=0.007). There was no change
in survival of non-HCV recipients between eras (p = 0.14), although graft
survival improved after 1994 and has remained stable since (p=0.02). The impact
of potentially detrimental changes in recipient demographics over the eras
including older patients, older donors, and a higher proportion with HCC have
likely been ameliorated by positive trends including shorter cold ischemia
time, fewer retransplants, greater use of tacrolimus and mycophenolate, and
less steroid-resistant rejection.
Conclusion:
1. Post-transplant survival after OLT
for chronic hepatitis C has improved significantly over the last 15 years
despite demographic changes in patients and grafts that have been previously
shown to impair survival.
2. A major reason for this improvement
is better selection of patients with concurrent hepatocellular carcinoma.
3. Risk factors for death in patients
with HCV post-liver transplant are:
a. CMV>3 months post-transplant
b. Recepient age > 60 years
c. Donor age > 50 years
d. Re-operation < 3 months
No donor organs were
obtained from executed prisoners or other institutionalized persons. The
authors have no conflicts of interest.
L. Lilly; N. Girgrah; G. Therapondos
Introduction/Aim:
Successful treatment of chronic hepatitis C virus (HCV)
infection is defined by undetectable serum HCVRNA six months following
cessation of antiviral therapy (sustained virological response; SVR). This
response seems highly durable in immunocompetent HCV patients, with rates
>96% reported after several years of follow-up. However, it is unclear
whether an immunosuppressed patient population will enjoy the same long term
success. We therefore examined our liver transplant patient population with SVR
to assess the durability of their response.
Patients:
Over 150 patients in the liver transplant program at our
institution have been treated for recurrent HCV; to date, 75 have achieved an
SVR. Qualitative HCVRNA determinations were made q3m for one year from cessation
of treatment, and annually thereafter, as well as during any rise in liver
enzymes.
Results:
39/75 patients (52%) were Genotype 1 (G1), and 24 (32%) were
G2 or G3, the remainder were other genotypes or
unknown. Two patients were transplanted for HCV/hepatitis B coinfection, and
had undetectable HBVDNA prior to treating HCV. All patients who had
undetecteable HCVRNA 3m following treatment achieved an SVR. Follow-up from SVR
ranged from 3m to 84m. Two patients died during the follow-up period, one 8m
and the other 22m from end of treatment; both were HCVRNA negative 2m prior to
death. Only one patient relapsed during the observation period. This patient
had received an HCV positive graft, and become HCVRNA negative on combination
therapy, remaining so for 18m after end of treatment. Retransplantation with
combined liver/kidney then took place and, 3m later, serum HCVRNA became
detectable.
Conclusions:
An SVR achieved in liver transplant patients appears to be as
durable as that seen in a non-transplant population, with the only relapse in a
patient who underwent retransplantation and had marked augmentation of
immunosuppression. Further, HCVRNA determination 3m after end of treatment may
suffice to define SVR in this difficult-to-treat population.
F. Feitosa; S. Radenne; T. Bizollon; A. dOliveira; P.
Pradat; R. Parana; C. Trepo
Context and objectives:
Liver biopsy is considered the gold standard to evaluate
outcome post liver transplantation. Because of its non invasiveness, hepatic
elasticity measurement (Fibroscan®) has increasingly gained attention for the
evaluation of fibrosis in transplanted patients. Our purpose was therefore to
compare Fibroscan® values with those of liver biopsy in patients transplanted
for HCV cirrhosis.
Patients and methods:
All consecutive patients transplanted for HCV cirrhosis who
underwent a medical visit at
Results:
15 patients (39%) had fibrosis lower than F2 at liver biopsy
and 3 (8%) were F4. For Fibroscan®, these results were 16 (42%) and 9 (24%),
respectively. The mean duration between the transplantation and the biopsy was
76,8 months (3-172) and 3,2 months between the
transplantation and the Fibroscan® (0-9). 17 patients (45%) had cleared HCV
following therapy. At the time of transplantation, 8 patients (21%) presented
already hepatocellular carcinoma on the explanted liver. The observed
concordance between the methods was 0,71 (27 patients)
and the expected concordance was 0,51. The sensibility of Fibroscan® was 0,76 (IC 0,58-0,94) and its specificity, 0,65 (IC 0,53-0,76)
with predictive positive and negative values of 0,72 and 0,65, respectively.
The prevalence and the corrected prevalence was 0,55
and 0,57. The positive likelihood ratio was calculated at 2,2
and the negative as 0,37. Intermethods reliability shows a Kappa index at 0,41 (IC 0,09-0,73; statistical significance> 0,5). The
comparison of all epidemiological and laboratory parameters between the two
groups (concordants and non-concordants) did not show any statistically
significant difference.
Conclusions:
·
Our
data failed to show a close correlation between Fibroscan® and the liver biopsy
in these patients.
·
This
discordance may be in part due to the high proportion of cases with mild
fibrosis that all the more it emphasizes the need for specific validation of
the Metavir Scores with Fibroscan® measurements in the context of
transplantation which warrant further studies.
I. A. Hanouneh; C. M. Miller; A. J. McCullough; R.
Lopez; F. Aucejo; A. E. Feldstein; N. N. Zein
While hyperinsulinemia and its associated metabolic syndrome
(MS) have been implicated in the progression of hepatic fibrosis in HCV
patients, little is known about consequences of MS after LT.
Aim:
Assess the interaction between MS and fibrosis progression in
patients with recurrent HCV after LT using serial liver biopsies.
Methods:
Using electronic pathology database, we identified all LT/HCV
patients with at least two post-transplant liver biopsies (1998–2006). MS was
defined using ATP III criteria at 1 year post LT. Ludwig-Batts scoring system
was used to stage all biopsies (408 biopsies from 95 patients). The first
biopsy that showed progression post LT was used for the time-to-progression
analysis. Univariable and multivariable logistic regression analysis was
performed to identify factors associated with fibrosis progression.
Results:
MS was present in 50% of patients. Median follow-up was 22
(Q25, Q75: 12.0, 31.2) months during which 71% of subjects had fibrosis
progression. Overall median rate of fibrosis progression was 0.08 unites per
month (Q25, Q75: 0.0, 0.17). By unvariate analysis, high HCV RNA at 4 months
post-LT (p<0.001), diabetes (p=0.046), CMV infection (p=0.006) and MS
(p=0.049) were associated with progression of fibrosis. In multivariate
analysis, MS was not associated with fibrosis progression during the first year
post-LT [OR=1.06, 95% CI: 0.49-2.26] but was independently associated with
progression of fibrosis beyond 1 year after LT (OR=6.3, p=0.017). High viral
load at 4 months post-LT (OR=1.1, p=0.004), steroid therapy for acute rejection
(OR=1.9, p = 0.05), and CMV infection (OR=1.9, p=0.01) were independently
associated with fibrosis progression. A Kaplan-Meier plot below outlines the
association between MS and fibrosis progression.
Conclusion:
MS, a potentially modifiable factor, is common and appears to
be strongly associated with long-term fibrosis progression in the setting of
recurrent HCV after LT.
Y. Calmus; C. Duvoux; G. Pageaux; M. Messner; P. Wolf;
L. Rostaing; C. Vanlemmens; D. Botta-Fridlund; S. Dharancy; J. Gugenheim; F.
Durand; M. Neau-Cransac; O. Boillot; O. Chazouillčres; I. Lonjon-Domanec; L.
Samelson; D. Samuel
Aim:
The aim of this randomized, double-blind study was to
determine the effect of placebo or maintenance therapy with ribavirin (RBV)
monotherapy, after a year of combination therapy with peginterferon-alfa 2a
(PEG-IFNα-2a) and RBV, on continued eradication of HCV after liver
transplantation (LT).
Methods:
The study enrolled 100 patients (age 53.2 ± 8.3; male 73.3%;
time since transplant 1.2 ± 118.0; Geno 1, 73.4%, Geno 2, 2.1%, Geno 3 5.9%,
Geno 4 2.0%) with recurrent HCV and a minimum of stage 1 fibrosis (METAVIR
scoring) on a liver biopsy obtained 1–5 years after LT. At inclusion, the
activity and fibrosis scores (METAVIR) were 1.67 ± 0.76 and 1.47 ± 0.70,
respectively. PEG-IFNα-2a and RBV were initiated at 90 µg/wk and 600 mg/d,
respectively, and increased to 180 µg/wk and 1000 mg/d or adjusted as a
function of hematological tolerance. At week 52, combination therapy was
discontinued and patients were randomized to RBV alone or placebo for a further
48 weeks (blinded). 75% of patients received tacrolimus and 25% cyclosporine.
Growth factor use was permitted.
Results:
After one year of combined therapy, 63 patients were negative
by PCR and randomized between RBV alone or placebo. At
78 weeks (6 months after combined therapy), a sustained virological response
(SVR) was obtained in 40% of ITT patients (40/100). At 30 months (M30) (6
months after the end of the maintenance period), 47% of the patients randomized
to RBV (16/34) and 55% of those randomized to placebo (16/29) had undetectable
HCV-RNA (NS). At M30, the histological activity score was 1.52 ± 1.08 (vs 1.63
± 0.74 at M12) in the RBV group and 1.72 ± 0.84 (vs 1.51 ± 0.88 at M12) in the
placebo group (NS). At M30, the fibrosis score was 1.52 ± 1.08 (vs 1.63 ± 0.91
at M12) in the RBV group and 1.72 ± 1.07 (vs 1.51 ±1.09 at M12) in the placebo
group (NS).
The fibrosis score marginally improved in the RBV group between
M12 and M30 (-0.14 [CI : -0.5;-0.22]), whereas it
worsened in the placebo group (+0.26 [CI : -0.02;+0.54])(p=0.07).
Conclusion:
·
After
1 year’s combination therapy with peginterferon alfa-2a plus ribavirin, a SVR
was achieved in 40% of patients following liver transplantation in ITT
analysis.
·
A
maintenance therapy with one year of ribavirin does not improve long-term
virological response, but may lead to an improvement in fibrosis score.
M. Orrego; R. Restrepo; B. Aguilar; V. Araya; K. D.
Rothstein; C. Manzarbeitia; D. J. Reich; S. Munoz
Introduction:
Hepatitis B reinfection (HBVr) occurs with a variable
frequency after receiving a HBcAb+ liver donor.
However, there is little data on clinical, serological and virological factors
associated with HBVr after LT.
Aim:
To determine the incidence of HBVr in LT recipients and to
identify clinical, serological and virological factors associated with HBVr.
Methods:
Retrospective analysis of our LT
population from June 1995 to May 2007. Non-HBV infected recipients with complete laboratory
data post LT were studied. HBVr was defined as a positive HBsAg or HBV DNA
>20,000 IU/ml post LT. Fisher’s exact test was used for group comparisons.
Results:
60 of 550 LT recipients (10.9%) received HBcAb+ donors. 42 of
60 patients met inclusion criteria. 6 of 42 (14%) LT recipients had HBVr.
Lamivudine prophylaxis was used post LT in 6% of the recipients. 74% of the
recipients had HCV infection. Median time for HBVr was 20.7 (5.8 to 110)
months. 76% were male. Mean age was 54.3 years.
We identified three different groups for HBV (table1). Of the
26 patients in the MG, one (4%) patient had HBVr. In the UG, 4 of 12 (33%)
patients developed HBVr. The UG had 8.7 (95%CI, 1.1 to 69) times the risk of
HBVr compared to the MG after LT (p=0.03). The remaining 4 patients were
vaccinated and one (25%) patient had HBVr.
There was no difference in HBVr in the vaccinated group
compared to the MG and the UG. To investigate HBVr by LT recipient diagnosis,
we compared HCV infected recipients (74%) to non-HCV recipients (26%). Of the
31 HCV infected recipients, 2 (6.4%, 95% CI, 0% to 21%) developed HBVr. In
contrast, 4 (36%, 95% CI, 10% to 69%) of the non-HCV recipients had HBVr. The
non-HCV recipients had 5.6 (95% CI, 1.2 to 27) times the risk for HBVr in
comparison with HCV infected recipients (p=0.03). Since both HCV infected
recipients and MG recipients appeared to be protected against HBVr, we tested
if the combination was also protective. 3 (60%) of the 5 recipients in the UG
with non-HCV diagnosis had HBVr compared to 0 of 22 recipients in the MG with
HCV infection (p=0.003).
Conclusions.
·
Serological
and virological characteristics have important implications to allocate HBcAb +
livers. Recipients in the matched group with HCV infection appear to be
protected from HBV reactivation after LT.
·
The
unmatched group and non-HCV recipients have higher risk of HBV reactivation and
therefore, HBV antiviral prophylaxis should be strongly considered.
·
HBVr
in the vaccinated group may have been explained for low HBsAb titers in the
recipient.
Table 1
|
Groups |
Matched
group (MG) |
Unmatched
group(UG) |
Vaccinated
group |
|
Donor |
HBcAb+ / HBsAb+ or - |
HBcAb+ / HBsAb+ or - |
HBcAb+ / HBsAb+ or - |
|
Recipient |
HBcAb+ / HBsAb+ or - |
HBcAb- / HBsAb - |
HBcAb– / HBsAb + |
533. High
Prevalence of Glomerulonephritis in Patients with End-stage HCV-induced
Cirrhosis
B. McGuire; B. A. Julian; J. Novak; S. Bynon; W. J.
Cook; S. Eddleman; D. E. Eckhoff
Introduction:
Patients undergoing liver transplantation for cirrhosis due
to hepatitis C virus (HCV) infection have a greater frequency of renal
insufficiency after liver transplantation compared to patients without HCV. It
is speculated that there is a greater prevalence of glomerulonephritis (GN) at
the time of liver transplantation, but there are no data to support this
postulate. The aims of this study were to determine the prevalence and type of
renal pathology with HCV-induced and nonviral-induced cirrhosis and to correlate
renal pathology with serum and urinary markers of renal disease.
Methods:
Forty adult patients undergoing liver transplantation for
cirrhosis (including 30 patients with HCV-induced cirrhosis previously
reported) were evaluated prior to liver transplantation for renal dysfunction
(serum creatinine), hematuria (dipstick > trace blood), and proteinuria
(urinary protein/creatinine ratio >0.3). At the end of transplantation, a
needle biopsy of the right kidney was done.
Results:
The clinical data for the six patients with nonviral-induced
cirrhosis included: mean age 55 yr (44-68), 5 men, and cause of liver disease
was 2 non-alcoholic steatohepatitis, 2 alcohol, 1 primary sclerosing
cholangitis and 1 cryptogenic. Hepatoma was present in 1 patient, diabetes in 3
and hypertension in 4. The mean calculated MELD score was 23. Preoperatively, 5
patients had one or more abnormal noninvasive study (3
elevated serum creatinine, 2 hematuria, and 2 proteinuria); 1 patient
had normal studies. Kidney biopsy showed 3 patients with IgA nephropathy (IgAN)
and 3 without GN. The clinical data for the 34 patients with HCV-induced
cirrhosis included: mean age 52 yr (41-73), 23 men, 13 hypertensive, 8
diabetic, and 2 had hepatorenal syndrome at engraftment requiring hemodialysis.
Mean calculated MELD score was 24.
Preoperatively, 19 patients had at least one abnormal
noninvasive study (13 elevated serum creatinine, 12
hematuria, and 7 proteinuria); 15 patients had normal studies. Kidney biopsy
showed 29 patients with an immune-complex GN (14 membranoproliferative GN, 9
IgAN, and 6 mesangial GN). No patient in either group had cryoglobulins by
electronmicroscopy or serum measurement. At liver engraftment, histologically
recognizable glomerular disease affected 29/34 (85%) of patients with end-stage
HCV cirrhosis versus 3/6 (50%) of patients with nonviral-induced cirrhosis (p =
0.05).
Conclusion:
·
Patients
with HCV-induced cirrhosis have a higher prevalence of immune-complex GN
compared to patients with nonviral-induced cirrhosis at the time of
engraftment.
·
These
findings may explain the decline in renal function that commonly occurs after
liver engraftment for HCV.
A. Samri; A. Roque-Afonso; O. Beran; C. Feray; E.
Dussaix; D. Samuel; B. Autran; J. Duclos-Vallée
Background:
Liver transplantation (LT) in HIV/HCV co-infected patients is
successful. Hepatitis C reinfection is the major cause of recipient mortality.
The aim of this work was to evaluate the immune responses against HCV before
and after LT in HIV/HCV co-infected patients.
Methods:
14 patients with HIV viral load (VL)<50
copies/mL and CD4 counts>200/mm3 receiving a graft for
HCV-cirrhosis were included. Patients were monitored for HCV and HIV VL, liver
histology and immune responses in pre- and post-transplantation course (2
years). T cell responses were evaluated in blood by IFN-γ-ELISpot assays
using recombinant (r) proteins: core, NS3, and NS4 (HCV), HIV-1-p24 and CMV,
PPD and candida, and 16 pools of HCV-peptides (core, NS3, and NS5) and 1 pool
of HIV-1-p24-peptides.
Results:
Before LT and 2 years after, median CD4 counts and HCV-VL
were 276 and 238/mm3 and 5.73 and 6.40 log
IU/mL. During the follow-up, T-cell responses against opportunistic antigens
were detected in 13/14 patients with median frequency of 245 SFC/106 PBMC
(range: 50 to 1677). 11/16 patients had responses against rHIV-1-p24 protein
with a median frequency of 110 SFC/106 PBMC (range: 50 to 930). HCV-specific
CD4 T cell responses were detected in 4 patients and directed against core in 3
patients (from 67 to 187 SFC/106 PBMC) and NS3 and NS4 in the fourth patient (87
and 50 SFC/106 PBMC). Ex vivo CD8 responses against HIV-1-p24 pool were
observed in 7/11 patients with a median frequency of 195 SFC/106 PBMC (range:
60 to 875) whereas responses against HCV-peptides were detected in 1 patient
and directed against core and NS5 (153 and 220 SFC/106 PBMC respectively). In 3
patients without ex vivo CD8 response, in vitro HCV-peptide stimulation lead to
generate responses directed against core in 1 patient (2340 SFC/106 PBMC) and
NS3 in 3 patients (from 203, 280 and 1460 SFC/106 PBMC). Interestingly, 6/7
patients with anti-HCV responses had also anti-candida responses vs 1/7
patients without anti-HCV responses. The seven patients with anti-HCV responses
had F0(n=3) or F1(n=2) or F2(n=2) (METAVIR) score at 2
years. 3/7 had undetectable HCV-VL. In patients with no anti-HCV response, the
scores observed were: F1(n=1), F2(n=1), F3(n=2) and
F4(n=3).
Conclusions:
Overall, higher levels of IFNγ secretion to HCV and
candida are associated with less severe fibrosis. Our results demonstrate that
immune responses against HCV modulate recurrence of HCV infection and severity
of liver histology after LT in HIV/HCV co-infected patients.
536. Serum
Levels Of Fibrosis Progression Biomarkers
Measured Early After LT Are Associated To Severe HCV Recurrence
D. Micheloud; M. Salcedo; S. Resino; D. Rincon; E.
Alvarez; G. Clemente; M. Catalina; J. Gomez-Camarero; R. Lorente; M.
Muńoz-Fernandez; R. Bańares
Background:
Severe hepatitis C (HCV) recurrence is the most important
influencing factor of survival after liver transplantation (LT). Portal
hypertension (PH) and fibrosis stage (FS) at 12th month after LT have been
associated to severe recurrence and poor survival. Several serum biological
markers have been proposed as predictors of fibrosis progression in
non-transplanted HCV infected patients.
Aims:
To analyze the relationship between the early expression (3 mo) of a serum panel of biological markers
related to progression of liver damage (TNF-alpha, IP-10, MCP-1, sICAM-1,
sVCAM-1, VEGF, HGF, Ang2, MMP9, TIMP-1 and hyaluronic acid) and severity of HCV
recurrence after LT.
Patients and Methods:
Thirty-seven consecutive LT recipients due to HCV (n=19) or
alcoholic (n=18) cirrhosis were included. All patients received tacrolimus or
cyclosporine based immunosuppression with steroids. In all cases rejection and
technical complications were excluded at the time of evaluation. Serum samples
were collected at 3 mo after LT. Severe HCV recurrence was defined as fibrosis
stage ≥F1 (Metavir score) in the one-year protocol biopsy and/or the
existence of a HVPG value ≥6mmHg. Values are expressed as median (IQR).
Results:
At one year, 12 out 19 patients had severe HCV recurrence. No
liver fibrosis was found in the biopsies performed in non-HCV patients.
Patients with severe HCV recurrence compared to non-severe HCV recurrence and
to non-HCV alcoholic patients presented at 3 mo significantly higher level of
IP10 [(820 (2409), 348 (280), 180 (240) pg/ml], sVCAM-1 [2466 (839), 1266
(916), 1354 (1330) ng/ml] and hyaluronic acid [624 (246), 434 (351), 326 (207)
pg/ml]. ROC curves were able to identify significant value to predict severe
recurrence in HCV positive patients: IP10>590: 0.74 (0.5-0.9);
sVCAM-1>1481: 0.89 (0.7-1); hyaluronic acid>461: 0.70 (0.5-0.9).
Conclusions:
·
Serum
levels of IP10, sVCAM-1 and hyaluronic
acid measured early after LT are associated to severe HCV recurrence.
·
Evaluation
of these biomarkers may be useful for early identification of patients with bad
prognosis in which a more aggressive therapeutic approach could be necessary.
C. Rigamonti; M. Donato; F. Agnelli; M. Fraquelli; G.
Casazza; G. Rossi; M. Colombo
Background and aims:
We previously demonstrated that TE reliably predicts severity
of graft damage in LT patients. However, to what extent TE helps monitoring
patients with recurrent hepatitis C under protocol liver biopsies (LB) needs to
be assessed.
Methods:
34 patients (28 males, median age 57
years) with recurrent hepatitis C, who underwent sequential protocol LB and TE
examinations twice, during a follow-up period of 18 months (first examinations
at 6-96 months, median 6, from LT). Grading and staging were assessed according to Ishak score
(grading 0-18; staging 0-6). TE examination was considered adequate if at least
ten valid measurements for each patient were obtained with a >65% success
rate. Changes in liver fibrosis and TE values were assessed as follows:
worsening fibrosis (wF) or improvement fibrosis (iF) was ≥1 point staging
increase or decrease, respectively; worsening TE (wTE) or improvement (iTE) was
defined as ≥30% increase or decrease of TE baseline value. Four groups were
identified: wF/wTE=group 1; iF/iTE or stable F/stable TE=group 2; wF/stable
TE=group 3; iF/wTE=group 4.
Results:
Median length of LB was 30 mm (range 15-60). At first
examination median grading was 7 (range 1-11), staging 1 (0-5), TE 6.9 kPa
(4.0-20.2). At second examination median grading 7 (range 1-13), staging 2
(1-6), TE 8.5 kPa (4.1-27.1). Changes in histological grading and staging
positively correlated with changes in TE values (r=0.47, p=0.005 and r=0.68,
p<0.0001, respectively). 11/34 (32%) patients were in group 1, 17/34 (50%)
were in group 2, 3/34 (9%) were in group 3, and 3/34 (9%) were in group 4. In
particular, in the group 3 staging worsened in one patient from 0 to 1, in the
other two from 1 to 2; only one had grading decreased from 9 to 5. In the group
4: one with stable staging had grading increased from 8 to 13; the second
developed de novo autoimmune hepatitis during follow-up, and the third had
severe intrahepatic siderosis. Overall, sensitivity and specificity of TE in
predicting wF were 79% and 85%, respectively.
Conclusions:
In patients with recurrent hepatitis C TE accurately
predicted wF. TE could spare the need for protocol LB in patients with iTE or
stable TE.
539. Patients
with HCV-Induced Cirrhosis with Immune-complex Glomerulonephritis Have
Progressive Proteinuria After Liver
Transplantation
B. McGuire; B. A. Julian; J. Novak; S. Bynon; W. J.
Cook; J. M. Vincent; D. E. Eckhoff
Patients undergoing liver transplantation for cirrhosis due
to hepatitis C virus (HCV) infection have a high frequency of renal failure
after liver transplantation. We have previously shown that immune-complex
glomerulonephritis (GN) is common and often subclinical in patients with
end-stage HCV-induced cirrhosis.
Aim:
The aim of this study was to determine the development of
clinical renal injury after liver transplantation of these patients.
Methods:
Twenty-seven patients with HCV-induced cirrhosis undergoing
liver transplantation were evaluated prior to surgery for renal dysfunction
(serum creatinine), hematuria (dipstick > trace blood), and proteinuria
(urinary protein/creatinine ratio > 0.3). At engraftment, a needle biopsy of
the right kidney was done. Clinical features included mean age 53 years
(41-73), 20 men, 22 Caucasians, hypertension in 10, diabetes in 6, and hepatoma
in 10. Mean MELD score was 25. Preoperatively, 12 patients had elevated serum
creatinine and 12 had 1 or more urinary abnormality (5
isolated proteinuria); 10 patients had normal noninvasive studies. Renal
biopsy showed 12 patients with membranoproliferative GN (MPGN), 6 with IgA
nephropathy (IgAN), 6 with mesangial GN (MesGN), and 3 with minor glomerular
abnormalities. At last follow-up, the noninvasive renal markers were repeated.
Results:
At last visit (1 or 2 years after transplantation), 11
patients had proteinuria (6 with MPGN, 3 with IgAN and 2 with MesGN). Of these
11 patients, 8 had no proteinuria at liver engraftment. Two of these 8 patients
underwent a second renal biopsy about 1 year after liver transplantation to
evaluate proteinuria. Histology showed worsening immune-complex-associated
glomerular injury without calcineurin inhibitor toxicity. Of the 7 patients who
were proteinuric at 1 year post-transplant, the Modified Diet in Renal Disease
(MDRD) estimated glomerular filtration rate was 48 ml/min/1.73 m2, compared to
69 ml/min/1.73 m2 for the nonproteinuric patients (p = 0.07).
Conclusions:
Proteinuria within two years after liver transplantation for HCV-induced
cirrhosis is common, even when the urinalysis was normal at the time of
engraftment. Patients with HCV-induced cirrhosis who develop proteinuria after
liver transplantation may have an underlying GN rather than calcineurin
nephrotoxicity and are likely to be at increased risk of progressive renal
dysfunction.
540. Fibrosis
Progression on Protocol Liver Biopsies In Patients
With Recurrent HCV Following Liver Transplantation
E. De Martin; S. Boninsegna; M. Senzolo; M. Guido; M.
Gambato; G. Germani; A. Masier; G. Zanus; U. Cillo; P. Burra
Background and Aim
The recurrence of hepatitis C following liver transplantation
(LT) is universal and it frequently leads to progressive fibrosis and cirrhosis
with poor outcome. The aim was to evaluate the progression of fibrosis on
protocol liver biopsies in patients transplanted for HCV cirrhosis.
Materials and Methods
A cohort of patients transplanted (1999-2005) for HCV
cirrhosis who underwent protocol liver biopsies consecutively performed at our Gastroenterology
Unit at 6, 12 and 24 months after LT were included in the study. Histological
stage of fibrosis was evaluated according to Scheuer (score 0-4). The fibrosis
progression rate (FPR) was expressed as fibrosis unit per month (FU/mo) and
compared over 2 periods (6-12 mo; 12-24 mo after LT). When indicated, patients
underwent PEG-IFN/Ribavirin antiviral therapy. Statistical analysis: Wilcoxon
rank, Friedman and Kruskal Wallis tests.
Results
54 patients underwent 3 serial and consecutive liver biopsies,
M/F 20/34, age 55±7yrs, follow-up 24-95mo. Overall, at 6, 12 and 24 months
after LT the stage of fibrosis 3 or 4 was reported in 3.7%, 7.4% and 13% of
patients respectively, stage of fibrosis (mean value) was 1.17, 1.20, 1.70
respectively, FPR was 0.005 FU/mo (6-12 mo) and 0.0416 FU/mo (12-24 mo). 9/54
(16,7%) underwent antiviral therapy, SVR was seen in
4/9 (44,4%) patients. At 6, 12 and 24 months after LT the stage of fibrosis 3
or 4 was reported in 0%, 11,1% and 22,2% of treated and in 4,4%, 6,7% and 11,1%
of non-treated patients, the stage of fibrosis was 1.44, 1.61, 2.11 in treated
(p=ns) and 1.12, 1.12, 1.61 (p=.003) in non treated patients, FPR was 0.0283
and 0.0416 in treated and 0 and 0.0416 in non treated patients at 6-12 and
12-24 mo respectively. According to SVR, at 6, 12 and 24 mo after LT, stage of
fibrosis 3 or 4 was 0%, 0%, 0% in SVR+ and 0%, 20% and 40% in SVR- patients,
stage of fibrosis was 1.25, 1.25 and 1.5 in SVR+ and 1.6, 1.9 and 2.6 in SVR-
patients, FPR was 0.00 and 0.02 for SVR+ and 0.05 and 0.06 for no SVR at 6-12
and 12-24 mo after LT respectively (p=ns).
Conclusion
·
The
fibrosis progression due to HCV recurrence is accelerated between the 1st and
2nd year compared to the early period after LT, with a lower stage and slower
FPR seen in patients who were not selected for antiviral therapy.
·
In
patients without SVR, pre-cirrhosis or cirrhosis is seen in 40% of cases at 2
years after LT.
M. Ghabril; R. C. Dickson; J. Lucas; J. Aranda-Michel;
A. Keaveny; B. Rosser; D. M. Harnois; H. Bonatti; R. Satyanarayana; W. R.
Hewitt; J. H. Nguyen
Background:
Treatment of Hepatitis C (HCV) after liver transplantation
(LT) with pegylated interferon/ribavirin (PEG) is associated with limited
sustained viral response (SVR). Consensus interferon/ribavirin therapy (CIFN)
may be effective after PEG non-response or relapse, but data is limited post
LT.
Aim: To evaluate outcomes of CIFN in HCV LT recipients not
achieving SVR with PEG.
Methods:
572 HCV patients received LT between 2/98 & 9/06 and 233
underwent antiviral treatment with PEG. Charts of patients without SVR to PEG
who were then treated with CIFN were retrospectively reviewed. Data up to
6/2007 were collected. Target dose interferon in PEG was defined as peg
interferon alpha-2a 180mcg or alpha -2b 1.5mcg/kg weekly and CIFN ≥ 9mcg
daily. Target dose ribavirin was ≥800 mg daily. Virologic endpoints were
SVR, relapse and virologic response (VR) defined as ≥ 2 log drop in HCV
RNA. Advanced fibrosis was defined as Batts Ludwig score ≥ 3.
Results:
34 patients who failed PEG (32 nonresponders/2 relapse) were
treated with CIFN and 16 remained on CFIN at last follow up. Mean age 51±7, 65%
males, 85% caucasian, 97% genotype 1. PEG & CIFN
treatments were compared in the same 34 patients (table). Patients achieving
target dose PEG and CIFN had similar VR (37% & 42%). Of the 21 patients
with no VR to PEG, 6(30%) had a VR to CIFN, while 4(22%) with no VR to CIFN had
a previous VR to PEG. A mean follow-up of 49 months post LT, 35% had advanced
fibrosis on last liver biopsy and 1 patient underwent re-LT for HCV related
graft failure.
Summary:
In patients without SVR to PEG after LT treated with CIFN,
treatment with either PEG or CIFN was limited by tolerance. Virologic endpoints
were similar between treatments though more than 20% with no VR to one
interferon had a VR response to another. SVR, the most critical treatment endpoint
was rare.
Conclusion:
CIFN for HCV recurrence after PEG treatment failure post LT
has limited efficacy. There remains a need for additional therapeutic
strategies in this difficult to treat group.
|
|
PEG |
CIFN |
|
Time from LT (months) |
*14±12 |
*37±22 |
|
Full dose interferon |
56% |
56% |
|
Full dose ribavirin |
44% |
50% |
|
Growth factors used |
79% |
84% |
|
Advanced fibrosis |
18% |
31% |
|
VR |
33% |
44% |
|
Relapse |
6% |
3% |
|
SVR |
0 |
3% |
|
Discontinuation due to intolerance |
24% |
32% |
*P
if <0.05
543. What is
the risk of HBV transmission in recipients of liver graft from HBc Positive
Antibody, HBs Negative Antigen donors? A single
center experience over 10 years.
B. Roche; A. Roque-Afonso; T. Antonini; M. Gigou; D.
Castaing; D. Samuel
Background :
Liver graft from HBc positive antibody (HBcAb), HBs antigen
negative (HBsAg) donors are used to expand the pool of graft despite a known
risk of HBV transmission. Various prophylaxis strategies were used in small
series to prevent the risk of HBV transmission. The aim of the present study
was to report our experience over 10 years using a prophylaxis with HBs
antibody immunoglobulins (HBIG).
Methods :
From 1997 to 2006, 80 HBcAb + liver grafts out of 947 grafts
(8.4%) were used. These grafts were used for 21 HBsAg positive recipients and
59 HBsAg negative recipients (HCV cirrhosis n=22, alcoholic cirrhosis n=14,
amyloid neuropathy n=11, miscellaneous n=12). Among the 59 HBsAg negative
recipients, 30 were HBsAb and HBcAb negative, 13 were HBsAb positive and HBcAb
negative and 16 HBcAb positive +/- HBsAb positive. HBsAg positive recipients
received a prophylaxis regimen using HBIG +/- antivirals according to
pre-transplant HBV vital load. Among HBsAg negative recipients, 44 received
HBIG prophylaxis using 10000 IU IV during anhepatic phase and reinjection of
5000 IU IV when HBsAb was below 100 IU/L.
Results :
Mean follow-up was 47.8 months (1-115.8). HBV infection occurred
in 13 recipients (16.2%) during follow-up at a mean delay of 15 months (6-45)
after transplantation. HBV DNA became positive in 13 patients and HBsAg in 12.
No HBV infection occurred in HBsAg positive recipients. HBV infection occurred
in 12 out of 30 HBsAb and HBcAb negative recipients (40%) and 1 out of 13 HBsAb
positive recipients (7.7%). Among the 30 HBsAb and HBcAb negative recipients,
HBV infection occurred in 7 out of 20 who received HBIG prophylaxis (35%) and 5
out of 9 who received no prophylaxis (55%). HBV infection of the graft was
treated with lamivudine in 13 recipients and adefovir was add-on in 6
lamivudine-resistant patients. A HBsAg / HBsAb
seroconversion was observed in 3 recipients during follow-up.
Conclusions :
The use of liver grafts from HBcAb positive, HBsAg negative
donors is relevant to expand the liver graft pool. These grafts should be used
in priority for HBsAg positive or HBV immune recipients (past infection or HBV
vaccination). This study confirms a high risk of HBV transmission for HBsAb and
HBcAb negative recipients despite HBIG prophylaxis. Future studies should
evaluate a combined prophylaxis with HBIG and antivirals in this group of
recipients.
L. Lilly; M. Deschenes; P. J. Marotta
Introduction/Aim:
Fibrosing cholestatic hepatitis C (FCHC) is an uncommon
(<5%) presentation of recurrent HCV following liver transplantation. It is
characterized by very high bilirubin and alkaline phosphatase and modestly
elevated transaminases, with a biopsy demonstrating marked cholestasis, minimal
necroinflammation, bridging fibrosis, and numerous apoptotic bodies. Outcome is
uniformly poor, and retransplantation generally unsuccessful. We examined the
response of FCHC to interferon/ribavirin therapy, using data collected from
three Canadian liver transplant programs.
Patients:
15 patients from the University of Toronto, University of Western
Ontario and McGill University Liver Transplant Programs who developed FCHC
following liver transplantation from 2000-2005 and received combination therapy
with interferon or PEG-interferon and ribavirin were included. All cases were
biopsy-proven, and antiviral treatment was commenced at 50-75% of standard
doses; growth factors were administered as required.
Results:
9/15 patients were male; mean age at transplant was 54y
[range 39-69y]. Nine received deceased donor, and five living donor, grafts. Ten
patients had genotype 1;
2 had genotype 2, 3 had genotype 4. Four patients received standard IFN and 11
patients received PEG IFN, in addition to ribavirin. 5/15 (genotype 1 = 3,
genotype 2 = 2) patients (33%) achieved an SVR, and 10/15 had no response.
Eight of these patients succumbed to liver failure 2-22m following FCHC
diagnosis; one patient is alive 6.5 yrs after
transplant with decompensated graft cirrhosis. Two of the five SVR patients
have since died, one from systemic sepsis 22m post transplant, and the other
17m post transplant from biliary tract complications.
Conclusions:
Combination therapy with interferon and ribavirin offers some
hope in the management of fibrosing cholestatic hepatitis (FCHC), although the
overall prognosis remains poor.
545.
Predicting Cardiovascular Events After Liver
Transplantation
M. Herman; S. Pungpapong; J. Aranda-Michel; B. Rosser;
D. M. Harnois; R. C. Dickson; R. Satyanarayana; D. Yip; A. Keaveny
Introduction:
Cardiovascular disease (CVD) is a leading cause of late death
post-liver transplantation (LT). CVD risk factors are common in LT patients.
The optimal method and timing of risk stratification for CVD post-LT are not
established. The
Methods:
This retrospective review of 120 consecutive first LT
recipients (65% male, mean age of 55 ± 10 yrs) followed subjects for a mean of
1601 days (range 233-1907) post-LT. Fasting total, HDL and LDL-cholesterol (TC,
HDL-C, LDL-C), glucose, weight and blood pressure (BP) were measured and FRS
calculated at pre-LT and regular intervals post-LT (at 4 and 12 months, then
annually). Diabetes mellitus (DM) was defined as plasma glucose >126 mg/dL
and/or the continuing requirement for DM therapy. Hypertension (HTN) was
defined as a systolic BP >140, diastolic BP >90 or the use of anti-hypertensive
agents. The change over time (slope) for risk factors was calculated and the
association between risk factor trajectory and CV events were examined with
logistic regression models.
Results:
9 non-fatal CVE's occurred in our cohort over the follow-up
period. CV risk factor data are shown (see Table) for selected visits.
Increasing body mass index (BMI) increased the odds of developing DM {OR 1.07
(95% CI 1-1.13), p<0.01}. The FRS slope correlated with CVE, {OR 1.4 (95% CI
1-1.9), p=0.04}.
Conclusions:
CV risk factors are prevalent and clinically useful over time
in U.S. LT patients. Changes in FRS over time identify patients at risk for CVE
post-LT, with the odds of CVE increasing by 40% for each 1-unit increase in
slope. Risk factor modification studies in this population appear warranted.
CV Risk Factors Pre and Selected Visits Post-LT
|
|
Pre-LT (n=120) |
4-month visit post-LT (n=120 |
Year 4 visit Post-LT (n=69) |
|
Mean time post-LT (days) ± SD |
- |
152 ± 66 |
1601 ± 164 |
|
BMI >30 (%) |
35% |
36% |
43% |
|
BMI >35 (%) |
14% |
11% |
15% |
|
Mean TC (mg/dL) ± SD |
151.5±49.5 |
174.1 ± 50 |
181.8 ± 46.9 |
|
Mean HDL-C(mg/dL)± SD |
40.2± 19.7 |
40.8 ± 14.3 |
48.8 ± 14.2 |
|
Mean LDL-C (mg/dL) ± SD |
92.1 ± 37 |
97.8 ± 42.4 |
96.8 ± 34.8 |
|
Prevalence of HTN(%) |
- |
59% |
72% |
|
Prevalence of DM (%) |
24% |
38% |
36% |
|
FRS ± SD |
5 ± 5.2 |
7.5 ± 7.2 |
7.7 ± 6.7 |
546. Transplantation
Trends in Recipients Over the age of
65
N. Kemmer; K. Safdar; T. E. Kaiser; V. Zacharias; M.
Atiq; K. Ahmed; N. Malik; G. W. Neff
Introduction:
Liver transplantation (LT) provides long-term survival for
adults with end-stage liver disease. As a result of improved survival and an
aging
Aim:
The aim of this study is to describe the transplantation
trends in the older recipient (65 yrs and older).
Method:
Using the UNOS database, we identified all LT recipients
between 1990 and 2006. The data collected included demographics, diagnosis, LT
year, survival information and UNOS region. We used Kaplan Meier method to
calculate overall survival (1, 3, 5 and 10 yr) and Cox regression modeling
techniques for predictors of survival.
Results:
During the study period 5630 (7.6%) LT recipients were >
65 years. Of these, there were 3030 (56.5%) males with a median age of 67
(range 65 – 87). There were 4256 (79.4%) Caucasians, Hispanic
(10.3%), African Americans (3.6%) and rest (6.7%). Hepatitis C (21%) was
the most common indication followed by cryptogenic (15.1%), alcohol liver
(13%), Hepatocellular Carcinoma (10.4%), Primary biliary cirrhosis 9.2%,
Primary sclerosing cholangitis 5.1% and others 26.2%. There was an increase in
LT for older patients from 4.1% in 1990 to 10.2% in 2006 (p=0.002), as well as
a regional variation (p<0.001). The 10-yr patient and graft survival was 60%
and 57% for <65 yrs vs. 42% and 40% for >65 yrs (p <0.0001).With age
stratification (65 – 75 yrs vs. >75yrs), there was no difference in overall
survival but when adjusted for race there was a significant difference in graft
survival with a 10 yr (Caucasian 40%, Hisp 44% and African Americans 19%)
(p=0.04). No other predictors of survival were identified.
Conclusion:
·
The
demand for LT in recipients older than 65 years is increasing; there is
regional variability and a change in LT indication (cryptogenic 2nd most
common).
·
Although
their survival is reduced when compared to recipients <65 yrs, there appears
to be no difference in unadjusted survival with age stratification above 65
years.
·
Among
ethnic minorities, African Americans have a disproportionately lower % LT and a
decreased survival
.jpg)
547. The
effect of disease recurrence on graft survival following orthotopic liver
transplantation
I. A. Rowe; K. Webb; B. K. Gunson; N. Mehta; S. Haque;
J. M. Neuberger
Introduction:
Disease recurrence following transplantation is well recognised
but since the impact of recurrence on graft survival is less clear we undertook
a retrospective analysis to determine both the frequency and impact of disease
recurrence on graft survival.
Methods:
All 1840 adult patients who underwent liver transplantation
between 1982 and 2004 were included. Disease recurrence was diagnosed on
clinical, serological, histological or radiological grounds as appropriate.
Where graft loss was due to factors associated with the indication (such as a
return to alcohol consumption), the graft loss was attributed to disease
recurrence. The most common disease indication was primary biliary cirrhosis
(PBC) so these patients were used as the comparison group. To eliminate those
grafts lost where recurrence was unlikely only those 1499 patients surviving
more than 90 days after transplantation were included in the analysis. The risk
of graft loss from disease recurrence for first grafts was calculated using the
Cox regression model.
Results:
The risk of graft loss from recurrent disease was greatest,
when compared to PBC, in those transplanted for hepatitis C virus (HCV) (hazard
ratio (HR) 11.6; 95% confidence interval (CI) 5.1-26.6), primary sclerosing
cholangitis (PSC) (HR 6.0; 95% CI 2.5-14.2) and autoimmune hepatitis (AIH) (HR
4.1; 95% CI 1.3-12.6). The overall risk of graft loss was also significantly
greater in HCV (HR 2.1 vs. PBC; 95% CI 1.5-3.0), PSC (HR 1.6 vs. PBC; 95% CI
1.2-2.3) and AIH (HR 1.6; 95% CI 1.0-2.4) although when recurrent disease was
excluded as a cause of graft loss there was no difference in the overall risk
of graft loss (HCV: HR 1.4; 95% CI 0.9-2.1, PSC: HR 1.4; 95% CI 0.9-2.0, AIH:
1.4; 0.9-2.2 all vs. PBC).
When the rate of disease recurrence and the rate of graft
loss from disease recurrence were compared, proportionally more grafts were
lost in HCV (14.3% of grafts lost to recurrent disease vs. 77% of grafts
affected), PSC (8.4% vs. 37%), and AIH (6.2% vs. 28%) than in PBC (1.3% vs.
24%). There was no statistically significant difference in the risk of graft
loss due to recurrent disease, when compared with PBC, for patients
transplanted for alcohol related liver disease (ALD) (HR 1.0;95% CI 0.2-4.9),
non-alcoholic steatohepatitis (HR 2.2;95% CI 0.6-8.4) and fulminant hepatic
failure (HR 1.7;95% CI 0.4-6.6).
Conclusion:
Disease recurrence is a significant cause of graft loss
particularly in HCV, PSC and AIH. Graft loss from disease recurrence in part
explains the increased overall rate of graft loss in these groups.
552. MELD-Na
is superior to other organ allocation systems
M. R. Foxton; P. Muiesan; N. Heaton; J. G. O'Grady; M.
A. Heneghan
Introduction
There is ongoing analysis of the optimal method of organ
allocation. The MELD system is inaccurate for up to 20% of the population on
the liver transplant waiting list.This is most likely due to significant
clinical variables such as ascites not being accounted for. We analyzed several
scoring systems for end-stage liver disease to assess which predicted survival
on the waiting list.
Methods
All patients listed with UK Transplant (UKT) at our centre,
between January 2000 and December 2003, were included in the study. Patients
were excluded if they were super-urgently listed, listed for multiple organ
transplants, non-NHS entitled for liver transplant or their indication for
transplant was amyloidosis. The scoring systems examined were the Child-Pugh
score, MELD score, MELD-Na score and three variants of the Child Pugh score
incorporating creatinine at the time of listing with UKT. A positive outcome
was surviving to transplantation or being delisted due to improvement obviating
the need for transplant. A negative outcome was death on the transplant list or
being delisted due to the developments of contraindications for transplant. Receiver-operating
characteristic (ROC) curves were generated for each scoring system based on
these outcome measures and the areas under the curve (AUC) were compared using
the Hanley-McNeil method.
Results
Seven hundred and eighty seven patients were listed. After
exclusions, 490 patients were analysed in the study. The median age of the
patients was 55 years and the predominant aetiologies were alcoholic liver
disease and hepatitis C. The median Child-Pugh score was 9 and the median MELD
score was 15. There were 416 patients with a positive outcome including 402
transplants. The remaining 74 patients with a negative outcome had
significantly higher CPS (11 vs 9), MELD (18 vs 14), MELD-Na (38 vs 16) and
modified CP scores (All p values <0.0001). There was no difference in time
on the waiting list (64 vs 68 days; p=0.18). The AUC for all scoring systems
was >0.705 (p<0.001) indicating that they performed well and were
clinically applicable. However, MELD-Na was significantly better than the other
scoring systems with an AUC of 0.828 (p<0.001).
Conclusion
·
All
scoring systems analysed performed adequately in predicting a negative outcome
on the transplant waiting list with no difference between CP score and MELD
score.
·
However,
MELD-Na was significantly better than all the other scoring systems at
predicting waiting list mortality and thus any changes in organ allocation
warrant comparison with this scoring system.
P. Manousou; D. Samonakis; A. Corbani; E. Cholongitas;
A. Sigalas; E. Xirouchakis; V. Calvaruso; F. Grillo; D. Patch; J. O'Beirne; A.
P. Dhillon; K. Rolles; B. Davidson; A. K. Burroughs
Introduction
Less potent immunosuppression has been considered to be
beneficial in reducing severity of HCV recurrence. However some reports suggest
benefit with low dose steroid maintenance. Optimal immunosuppression regimen is
unknown.
Aim of the study
To evaluate benefit of tacrolimus
monotherapy versus triple therapy in a randomized trial.
Patients and methods
88 consecutive patients with first transplant for HCV
cirrhosis with/without HCC were randomized to tacrolimus (MT) 0.1 mg/kg/day in
2 divided doses, or the same tacrolimus dose with 1mg/kg azathioprine and 20mg
prednisolone daily (TT) the latter was tailed off to zero at 3-6 months.
Patients had scheduled biopsies with Hepatic Venous Pressure
Gradient (HVPG) measurement yearly. Fibrosis was staged using Ishak score and
stage 4(F4) was the predetermined end-point. Cox regression was used to
evaluate factors associated with F4: age and gender of recipient and donor,
histological acute hepatitis, rejection episodes, HCC before LT, addition of
MMF, and allocated treatment.
Results
Randomization resulted in no significant differences in pre,
peri or post operative variables (median follow up 48 months). Mortality was
not significantly different: 8 of 43 in MT at 1m, 1m, 1m, 2m, 3m, 4m, 4m, 6m
and 5 of 45 in TT at 5m, 7m, 11m, 37m, and 66m). Retransplantation in 3 MT and
3 TT; frequency of scheduled biopsies was similar. During follow up
(re-transplants censored), 13 MT and 6 TT reached F4. Cox regression revealed
that randomization to therapy and episodes of acute hepatitis were two factors
independently associated with F4 (p=0.036). Kaplan Meier analysis showed TT
patients had significantly slower progression (p=0.048) than MT patients. HVPG
gradient was available in 33 MT and 30 TT patients. Kaplan Meier analysis
showed a significantly shorter time to reach HVPG≥10mmHg in MT group
compared to TT group (p=0.038).
Conclusion
·
The
use of low dose azathioprine long term and short term low dose prednisolone in
addition to tacrolimus in HCV cirrhosis recipients resulted in a slower onset
of histological severe fibrosis and portal hypertension compared to tacrolimus
alone, independent of other factors known to affect fibrosis.
·
This
randomized trial supports observational reports of the benefit of low dose
steroids, as well as azathioprine, used as maintenance immunosuppression after
liver transplantation for HCV positive recipients.
S. Patel; I. Lent; A. Bozorgzadeh; M. Orloff; G.
Tsoulfas; R. Kashyap; A. Jain; P. Abt
Introduction:
Living donor liver transplantation (LDLT) has become an
accepted alternative to transplantation with a cadaveric organ. Recently,
cadaveric donor characteristics as codified by the Donor Risk Index (DRI) have
illuminated the requirement to balance donor qualities and recipient risk of
death on the wait list as a means to optimize the survival benefit of
transplantation. Within this framework, the role of the living donor graft
remains unclear.
Methods:
Utilizing United Network for Organ Sharing data from 2002 to
2006, we analyzed graft survival comparing 4 different graft types stratified
by donor risk characteristics: low-risk living donor (LRLD – Relative Risk [RR]
of graft loss <1.7), high-risk living donor (HRLD, RR >1.7), low-risk
deceased donor (LRDD, <1.7) and high-risk deceased donor (HRDD, RR >1.7).
Graft survival was modeled using Cox regression while controlling for recipient
characteristics, which included age, race, diagnosis, dialysis, medical
condition, life support and Model for End-Stage Liver Disease (MELD) score.
Results:
98% of LDLT transplants were performed in recipients with a
MELD score of 25 or less. Overall 3 year graft survival for LRLD, HRLD, LRDD,
and HRDD was 77%, 65%, 80%, and 67%, respectively (p-value < 0.001) (Fig.
1). The relative risk of graft loss, in reference to the LRLD group, was 1.7
for HRLD (95% CI 1.05-2.75), 0.9 for LRDD (95% CI 0.72-1.12), and 1.4 for HRDD
(95% CI 1.18-1.86).
Conclusions:
·
Survival
with high risk living donor grafts is similar to high DRI cadaveric organs in
patients with low to moderate MELD scores.
·
Consideration
of donor characteristics relative to recipient risk of wait list death should
be considered in LDLT.
558. Smoking
related morbidity and mortality post liver transplantation
J. A. Leithead; J. W. Ferguson; P. C. Hayes
Introduction:
The negative health implications of cigarette smoking in the
non-transplant setting are well recognised. However, the morbidity and
mortality associated with tobacco use amongst liver transplant recipients
specifically remains unclear. The aim of this study was therefore to assess the
influence of smoking on both short and long term outcomes post liver
transplantation.
Methods:
A single-centre retrospective case-note study of 136
consecutive patients transplanted between
Results:
Of the remaining 108 patients, 23% were smokers, 18% were
ex-smokers and 58% were non-smokers. No difference was observed between the two
groups with regards age, gender, prevalence of HCC, Child Pugh score, listing
renal function, and the presence of pre-transplant diabetes, hypertension and
cardiovascular disease. Post transplant a similar proportion of patients in
each group received cyclosporin, and were treated for diabetes, hypertension
and hypercholesterolaemia.
All cause mortality
·
Smoking
at the time of assessment was associated with increased all-cause mortality,
the estimated 1, 5, and 10 year survival was 94% ,68% and 54% respectively for
active smokers and 94%, 83%, and 77% for life-long non-smokers (p=0.04).
·
This
increased risk of death was not maintained in ex-smokers (p=ns).
·
On
multivariate analysis only smoking (HR2.23, 95% CI 1.08-4.61, p=0.03) and
peri-operative renal replacement therapy (HR 2.78, 95% CI 1.35-6.74 p<0.01)
were independent predictors of death.
Conclusions:
·
Smokers
are 2 times more likely than non-smokers to die post liver transplantation
during a follow-up period of 10 years.
·
This
increased mortality rate is non-graft related and appears to be a result of
increased cardiovascular-related and sepsis-related death.
·
Prospective
studies are required to assess the impact of smoking cessation on long term
outcome.
561. Combined
liver heart transplantation in the
H. S. Te; S. R. Mohanty; N. Reau; K. G. Reddy; R.
Satoskar; D. M. Jensen
Introduction:
Combined liver-heart transplantation has been increasingly
performed in the
Methods:
Patients who received combined liver-heart and
liver-heart-kidney transplants were identified from the UNOS Database.
Demographic characteristics such as age and gender, and clinical data such as
indication for transplantation, duration of follow-up, current
immunosuppressive agents, complications, patient and graft survival times, and
cause of death were obtained.
Results:
From October, 1987 to February, 2007, a total of 47 cases of
combined liver-heart (n=41) and liver-heart-kidney transplantation (n=6) were
performed in the
Conclusion:
Combined liver-heart and liver-heart-kidney transplantation
is a viable option for candidates who need the combined organ transplantation,
with outcomes comparable to those of single organ recipients.
X. Xiol; P. Gines; L. Castells; A. Ribalta; J. Twose;
C. Ventura; J. Reverter; X. Fuentes; R. Deulofeu
MELD score is considered an objective and reproducible
measure of liver disease severity. However, MELD score can be influenced by
specific laboratory methodologies. In order to implement an organ allocation
system based on MELD score in the three Hospitals of Barcelona with liver
transplant program, all patients in the waiting list at the three centers were
studied simultaneously: blood samples were obtained from each patient and
divided in three aliquots, which were processed in the three laboratories. Two
laboratories (A, C) expressed creatinine and bilirubin in mg/dl and one (B) in
µmol/l. Therefore, a conversion factor was used in laboratory B (creatinine x
0.0113 and bilirubin x 0.0588). MELD was calculated according to the reported
mathematical formula.
Results:
74 patients, 51 from hospital A, 15
from B and 8 from C, were studied; 4 cases had a missing value and were
excluded. Overall, there were significant differences in the three laboratory
parameters, the greatest difference being in INR. Mean values and 95% CI for
each variable are shown in the table.
MELD score was identical in the three centers in only 6 out
of the 70 patients (9%). Scores from laboratories A and C differed
considerably: 22 cases had a difference of 1 point, 21 cases of 2 points, 10 cases of 3 points and in 7 cases the difference was
greater than 3 points.
Conclusions:
·
There
were significant differences in the three laboratory variables and in the
calculation of MELD score among the three centers.
·
In
two of them, MELD score differed in two points or more in 38 out of the 70 the
cases (54%). In order to guarantee an equitable organ allocation based on MELD
score, similar laboratory methodologies should be implemented in centers that
belong to the same organ procurement area, so that relevant differences in
calculated MELD scores are avoided.
·
Alternatively,
the existence of a central laboratory in each organ procurement area should be
considered.
|
|
Laboratory A |
Laboratory B |
Laboratory C |
p |
|
Creatinine mg/dl |
1.23 (1.05-1.42) |
1,20 (1-1.40) |
1,21 (1.03-1.41) |
0.001 |
|
Bilirubin mg/dl |
2.96 (2.29-3.64) |
3.28 (2.47-4.09) |
3.11 (2.38-3.84) |
0.001 |
|
INR |
1.40 (1.32-1.48) |
1.52 (1.42-1.61) |
1.67 (1.51-1.83) |
0.001 |
|
MELD |
14.3 (13.8-16.3) |
15.1 (13,1-15.4) |
15.9 (14.6-17.3) |
0.001 |
|
MELD range |
6-29 |
6-31 |
6-40 |
|
566. Outcomes
of Transplantation with previously Refused Donor Livers in Region 8
S. L. Eswaran; E. R. Lyden; T. M. McCashland
Intro:
There is a 10-20% mortality for
patients awaiting liver transplantation (LT). There are various refusal reasons
(RR) for donor livers (DLs). After refusal, DLs may be offered to another
patient or center.
Aim:
Evaluate the frequency of RR and outcomes of LT with
previously refused DLs. Methods: We requested data from UNOS-OPTN between July
2004-June 2006 in Region 8 regarding donors and recipients who received living
and deceased livers on the first offer (Group A) and who received previously
refused livers (Group B). We determined graft survival (GS) and patient
survival (PS).
Results:
Eleven centers were offered 764 DLs (Group A=315;41% and Group B=437;59%). The mean number of DL refusals
was 12.64 (range 1-221). The most common RRs were donor age/quality (37%),
donor size/weight (35%) and transplant center personnel limitations (10%),
including heavy work load, operational, or surgeon unavailable. Group B had
more male recipients (59% vs 72%; p=0.0003), older donor age (35 vs 38 yrs;p = 0.013), longer cold ischemic times (CIT) (6.23 vs. 7.42
hrs; p<0.0001), shorter warm ischemic times (WIT) (47.18 vs 42.8 hrs;
p=0.003) and shorter length of hospitalization post LT (19 vs 14 days;p=0.003).
There was no difference in 1 month (92% vs 94%) and 1 year (83% vs 85%) GS
(p=0.20, 95% CI).(Figure) Group B had a longer PS (86% vs 91%) at one year
(p=0.0069, 95% CI); however, when adjusted for gender, donor age, CIT, WIT and
length hospitalization post LT, a previously refused status was no longer
associated with a longer PS.
Conclusion:
·
There
were differences between recipients who received first offer donor livers (DLs)
and recipients who received refused DLs with respect to recipient gender, donor
age, CIT, WIT and length of hospitalization post LT; however, there was no
difference in PS of the two groups after adjusting for these LT variables.
·
GS
is equivalent in LT with previously refused DLs compared with first offer DLs.
576. Sexual dysfunction
before and after liver transplantation (LT).
L. Grellet; P. Perney; H. Rigole; Y. Duny; D. Larrey;
F. Blanc; G. Pageaux
Sexual disorders are frequently described in patients with
cirrhosis, often related to the endocrine consequences of advanced liver
disease. It is assumed that LT will help to recover from these symptoms.
Aim :
To report on the prevalence of sexual dysfunction in liver
transplant patients before and after LT, emphasizing the potential recovery of
pre-LT disorders and the occurrence of de novo post-LT disorders.
Methods :
During a direct interview, a sexual history was taken by a
sexology medicine specialist in all liver transplant recipients seen at the
out-patient clinic between may and december 2006. Exclusion criteria were : age
< 18 or > 70, LT < 6 months, evolutive cancer, interferon treatment
for HCV reinfection, severe renal or cardiac dysfunction. The following domains
were assessed : hypoactive sexual desire in men and women, erectile dysfunction
in men and inadequate vaginal lubrication in women, premature or delayed or
absent ejaculation in men, orgasmic disorder in women, pain with intercourse in
men, dyspareunia or vagisnismus in women.
Results :
93 pts fulfilled the inclusion criteria and 89 accepted to complete
the study. There were 64 males, mean age 54 ± 9 yrs and 25 females, mean age 51
± 10 yrs. Indication for LT were : alcoholic liver disease in 52, virus in 15,
alcohol plus virus in 9, others in 13. The mean delay form LT was 55 months
(6-225).
Evolution of sexual disorders before and after LT :
hypoactive sexual desire was present in 29 % of male and 40 % of female, and
improved in 73.6 % of male and 0 % of female. Erectile dysfunction was present
in 39 % of male and improved in 68 % of them. Inadequate lubrication was
present in 24 % of female and improved in none. Premature ejaculation was
present in 21 % of male and improved in 7 % of them. Orgasmic disorder was
present in 14 % of male and 36 % of female and improved in 66 % of male and 11
% of female. Pain was absent in male and present in 1 female before and after
LT.
De novo sexual disorders after LT : hypoactive sexual desire
was present in 6.2 % of male and 12 % of female. Erectile dysfunction was
present in 14 % of male. Premature ejaculation was present in 3 % of male.
Orgasmic disorder was present in 3 % of male.
Conclusion :
Sexual disorders were frequent in liver transplant patients
before LT. They frequently improved after LT in male, but almost never in
female. This point emphasizes the unclear impact of advanced liver disease in
women’s sexual dysfunction. De novo sexual disorders after LT were unusual.
Overall, 34.8 % of liver transplant recipients experienced sexual disorder.
This will need further attention.
585. Trends
in Liver Transplantation for Hepatocellular Carcinoma in the United States.
B. H. Leach; J. Prather; D. Scott; D. Norman; J. M.
Schwartz
Background:
Liver transplantation (LT) is an effective treatment for
select patients with hepatocellular carcinoma (HCC). HCC patients who meet
criteria are prioritized for liver allocation in 11 US geographic regions. It
is unclear if the priority allocated for HCC accurately reflects risk of death
or withdrawal from the waiting list. Furthermore, details regarding regional
differences in transplantation rates, deaths on the waiting list or waiting
list removal for HCC are unknown.
Aims:
1) To evaluate transplantation rates and waiting list
mortality for HCC patients and non-HCC patients listed for LT, and 2) To
compare regional rates of LT, waiting list mortality and waiting list removal
in patients with HCC.
Methods:
Data regarding 71,428 adult deceased donor LT candidates who
were on the list between February 2001 and January 2007 were obtained from the
United Network of Organ Sharing. Patients with a primary or secondary diagnosis
of HCC or those with an HCC exception were identified. Rates of
transplantation, waiting list removal and death on the waiting list were
expressed as the number of events/patient year according to the pre-MELD period
and four periods of MELD priority assigned to HCC patients. Rates of
transplantation, regional rates of transplantation for HCC, waiting list
removal and waiting list mortality were compared using unadjusted crude rate
analysis.
Results:
LT rates for HCC increased from 0.2/patient year prior to the
MELD era to 1.5/patient year in MELD era 4 (p<0.05). HCC LT rates increased
during the 4 MELD eras (1.1/patient year-1.5/patient year, (p<0.05). LT
rates for HCC varied according to UNOS region (range 0.77/patient year in
region 5 to 3.68/patient year in region 3, p<0.05). LT rates were higher for
HCC patients compared to non-HCC patients (1.25/patient year vs. 0.28/patient
year respectively, (p<0.05), and death rates on the waiting list were lower
in HCC patients (0.08/patient year vs. 0.11/patient year, p <0.05). Waiting
list removals were similar for HCC patients and non-HCC patients (0.27/patient
year vs. 0.26/patient year respectively, p=NS).
Conclusions:
1) Rates of LT for HCC have increased, however, rates vary
substantially according to geographic region; 2) Unadjusted waiting list
mortality is lower in HCC patients than non-HCC patients despite equivalent
drop out rates. Appraisal of the long term impact of allocation policies for
HCC is therefore necessary to provide equitable access to LT.
589.
Pre-transplant variables predict qualify of life in liver transplant recipients
S. Saab; B. Surti; A. Ibrahim; F. A. Durazo; S. B.
Han; H. Yersiz; D. Farmer; R. M. Ghobrial; L. Goldstein; M. J. Tong; R.
Busuttil
Introduction:
With an increasing number of liver transplant recipients
living, understanding quality of life issues is essential. Our goal is to
specifically identify the pre-transplant predictors of post-transplant quality
of life in liver transplant recipients. Understanding how these variables will
affect quality of life can help determine if specific interventions will
further improve quality of life post-transplant.
Methods:
Three hundred and eight adult liver transplant recipients
seen at UCLA were administered the Short Form 36 and a questionnaire regarding
work history and insurance coverage. Variables associated with post-transplant
quality of life were studied in a multivariate analysis. Interaction terms were
used to examine effect modification.
Results:
The mean age of participants (± standard deviation [SD]) was
51 (± 13.99) years. Most patients (50%) were transplanted for viral hepatitis. Post-transplant
quality of life domains were associated with a number of pre-transplant
factors: Physical Functioning (work hours, gender, ethnicity), Role-Physical
(work hours, body mass index, renal failure, ascites, and pay change post
transplant), Bodily Pain (ascites, pay change), General Health (encephalopathy,
ascites), Vitality (ascites), Social Functioning (disease etiology, ascites),
Role-Emotional (ascites), and Mental Health Factors (work hours).
Conclusions:
Our results demonstrate that pre-transplant factors such as
work hours, body mass index, renal failure, and disease etiology predicted
impaired quality of life in liver transplant recipients. In addition,
pre-transplant manifestations of portal hypertension such as ascites and
encephalopathy continue to affect patients even after transplantation.
Interventions to modify these pre-transplant variables may further improve
quality of life in liver transplant recipients.
|
Pre-transplant Variables |
Quality of Life Domain that
is Impaired |
Coefficient |
p-value |
|
Ascites
|
Role-Physical |
-11.73 |
0.01 |
|
Bodily Pain |
-14.17 |
0.02 |
|
|
Social Functioning |
99.58 |
0.04 |
|
|
Role-Emotional |
-33.01 |
0.02 |
|
|
Encephalopathy
|
General Health |
-16.70 |
0.02 |
|
Renal Failure
|
Role-Physical |
-1.80 |
<0.01 |
|
Disease Etiology
|
Social Functioning |
28.47 |
0.01 |
|
Work Hours
|
Role-Physical |
0.32 |
<0.01 |
|
Mental Health Factors |
0.54 |
0.05 |
|
|
Pay change
|
Role-Physical |
-2.10 |
<0.01 |
|
Bodily Pain |
-0.69 |
<0.01 |
|
|
General Health |
-1.10 |
<0.01 |
|
|
Body Mass Index
|
Role-Physical |
0.02 |
0.04 |
|
Gender
|
Physical Functioning |
8.83 |
<0.01 |
|
Ethnicity
|
Physical Functioning |
1.51 |
0.03 |
593. GB Virus-C
Infection is Associated with Better 10-Year-Survival of Liver Transplant
Recipients
K. Rifai; S. Pischke; S. Heringlake; H. Wedemeyer; J.
Klempnauer; C. P. Strassburg; M. P. Manns; H. L. Tillmann
Background & Aims:
We earlier demonstrated a beneficial influence of the GB
virus C (GBV-C, or hepatitis G virus) on the long-term course of HIV infection.
An influence of GBV-C on the short-term survival of liver transplant recipients
was not observed. Here we describe the long-term outcome of patients with GBV-C
after liver transplantation (OLT).
Methods:
We studied overall survival rates of 200 patients
transplanted at our center between 1992 and 1996. GBV-C envelope antibodies
(anti-E2) and RNA were tested directly before transplantation. 63/200 patients
had anti-E2, 17 patients were viremic and in 8 patients both GBV-C antibodies
and RNA were found. There were no differences regarding diagnosis, age or sex
between the different groups. Survival rates were assessed in 2006, thus 10
years after OLT, by using Kaplan-Meier and Cox's regression analysis.
Results:
Overall 1-, 3- and 10-year patient survival rates were 75%,
69% and 56%. Mean patient and graft survival was 7,8±5,5
and 7,1±5,5 years, respectively. A worse outcome was found for patients requiring
retransplantation (p<0.0001) and those with tumor disease (p<0.0001). If
patients surviving at least 3 years were analysed, those who were GBV-C RNA
positive had a significantly longer survival than RNA-negative patients. In
Cox’s regression including patient age and sex, need of retransplantation and
presence of tumor disease, GBV-C viremia (p<0.03) and absence of
retransplantation (p<0.04) were independently associated with patient
survival.
Conclusions:
·
Patients
with active GBV-C infection showed longer survival after liver transplantation,
once they survived the first 3 years.
This actually is in line with data from renal transplant recipients.
Discussion:
·
We
would speculate that GBV-C might ameliorate immune activation status,
explaining both improved outcome in HIV and organ transplantation.
P. J. Thuluvath; D. L. Segev
HCC in the presence of HCV may have a worse outcome after LT
because of the confounding effects of recurrent HCV and higher HCC recurrence.
Our objective was to assess the survival of patients with HCC in those with HCV
and non-HCV cirrhosis using UNOS database from 1994-2006.
Methods:
Patients with HCC were stratified into HCV (HCC-HCV) and
non-HCV (HCC-non HCV)and also into MELD and pre-MELD
era because of the potential impact of MELD on outcomes. In the pre-MELD era,
there were 1,886 HCC patients (639 HCV, 1,079 non-HCV, HCV
status unknown in 168) and during MELD era, there were 798 patients (283 HCV,
431 non-HCV and 84 unknown). For the purpose of this study, we analyzed
patients with unknown HCV status separately (not shown). Comparative analysis
was made of HCV (HCV) and non-HCV (non-HCV) patients without HCC after
stratification as discussed above. We calculated unadjusted graft and patient
survival rates (%) at 1, 3 and 5 years for pre-MELD and 1 and 3 years for MELD
patients.
Results:
Pre-MELD era – graft survival rates for HCC-non HCV was
higher than HCC-HCV patients at 1-yr (77.7 vs. 73.8), 3-yr (63.3 vs. 58.2) and
5 years (56.8 vs. 48.7); pre-MELD era patient survival was similar at 1-yr
(80.7 vs. 79.4) and 3-yr (66.2 vs.64.5), and higher at 5-yr (59.9 vs.55.2) for
HCC-non HCV. Pre-MELD era graft survival rates for patients without HCC in
non-HCV at 1-yr (80.6 vs.79.7), 3-yr (74.4 vs. 69.3) and 5-yr (69.2 vs. 61.8)
was also higher than HCV patients as expected; similar trend was also seen for
patient survival at 1-yr (85.2 vs. 84.1), 3-yr (79.7 vs. 74.5) and 5-yrs (74.8
vs. 67.3).
MELD era – graft survival rates were similar for HCC-non HCV
and HCC-HCV patients at 1-yr (83.7 vs. 82.7), but was higher at 3-yr (72.2 vs.
65.7); MELD era patient survival was similar at 1-yr (87.1 vs. 86.6) and was
higher at 3-yr (77.3vs. 71.9). MELD era graft survival rates for patients
without HCC in non-HCV at 1-yr (82.1 vs. 82.7) and 3-yr (74.5 vs. 69.7), and
patient survival 1-yr (86.7 vs. 5.4) and 3-yr (81.3 vs. 76.5) showed similar
trend. Survival differences showed similar trends as shown in the table.
Conclusions:
·
There
has been an improvement in 3-year graft (8.9% for non-HCV, 7.5% for HCV) and
patient (14.8% for non-HCV, 13.1% for HCV) survival in MELD era compared to
pre-MELD era for HCC patients with similar trends in survival rates in HCV and
non-HCV patients with and without HCC suggesting that lower survival in
patients with HCV and HCC is mainly due to the confounding effect of HCV.
|
|
Graft Survival Difference (%) |
Patient Survival Difference (%) |
||||
|
Year |
1-yr |
3-yr |
5-yr |
1-yr |
3-yr |
5-yr |
|
Pre-MELD
Non-HCV vs. HCV (no HCC) Non-HCV vs. HCV (HCC) MELD
Non-HCV vs. HCV (no HCC) Non-HCV vs. HCV (HCC) |
+0.9 +3.9 +0.8 +1.0 |
+5.1 +5.1 +4.8 +6.5 |
+7.4 +8.1 NA NA |
+1.1 +1.3 +1.3 +0.5 |
+5.2 +1.7 +4.8 +5.4 |
+7.5 +4.7 NA NA |
H. Rigole; P. Perney; M. Bismuth; F. Navarro; D.
Larrey; F. Blanc; G. Pageaux
It is important, but not always performed, to ascertain an
alcohol history in all patients undergoing liver transplantation (LT). However,
the points of view of addiction specialists and LT specialists differ about
their consideration of alcoholic disease.
Aim :
Assessment of alcohol behavior in LT candidates by an
addiction specialist in order to appreciate this specific approach.
Methods :
All patients were seen during the pre-transplant evaluation
by an addiction specialist. The diagnostic systems used to assess alcohol
disorders were WHO classification, DSM-IV and Babor’s classification. The
following characteristics were considered as predictive of severe alcohol
relapse after LT : alcohol dependence, young age, number of withdrawals, family
history of alcohol abuse, associated drugs addictions. During the evaluation, a
brief intervention about alcohol disorders was performed, and a specific
management of alcohol abuse was proposed, not imposed, to all patients with
predictive factors of severe relapse after LT.
Results :
80 patients have been studied. The primary indication for LT
was alcoholic liver disease (ALD) in 39 patients, HCV in 20 patients, HBV in 11
patients, others in 10 patients. Abnormal alcohol behavior was present in 57 of
the 80 patients : the 39 ALD patients, 13 of 20 HCV patients, 5 of 11 HBV
patients. Among these 57 alcohol abusers, 28 were excessive drinkers without
dependence and 29 were alcohol-dependant : 19 of 39 ALD patients, 6 of 13 HCV
patients, 4 of 5 HBV patients. Predictive factors of severe alcohol relapse
after LT were found in 19 patients, 17 of alcohol-dependant patients and 2 of
excessive drinkers. Only one of these 19 patients had accepted a pre-LT
management of alcohol disorder. During the follow-up, 3 patients died, 1 was
withdrawn from the waiting list, 41 are still on the waiting list and 35 have
been transplanted : 20 ALD, 8 HCV, 7 others. With a mean follow-up of 6 months
(3-16), no severe relapse was observed.
Conclusion :
A specific assessment of LT candidates by an addiction
specialist has detected 71 % of alcohol abusers and 36 % of alcohol dependant patients.
Moreover, among patients with viral liver disease, 58 % were alcohol abusers
and 32 % were alcohol-dependant. Predictive factors of severe alcohol relapse
after LT were found in 23,7 % of patients. Among these, the majority did not
adhere to a rehabilitation program. The impact of the pre-LT brief intervention
is under evaluation. These preliminary results are in favour of the
intervention of an addiction specialist during the evaluation of LT candidates.
602. The
Readability of Health Education Materials for Liver Transplant Patients
N. M. Lee; A. Muir; C. Brady
The listing process for liver transplantation (LT) is complex
and requires patients to comprehend their disease and aspects of LT care.
However, millions of adult Americans are illiterate and may not benefit from
printed LT educational tools. Laws require many public documents to be written
at an eighth-grade level or lower to ensure readability.
Aims:
(1) To determine the readability of printed LT educational
brochures,
(2) to quantify educational levels
of patients listed for LT, and
(3) to determine if demographic
factors are associated with patient educational level.
Methods:
We used the United Network for Organ Sharing database to
identify
Results:
Of 60,222 patients, 22,533 (37.42%) were female and 37,689 (62.58%)
were male; 3043 (5.05%) had less than high school education; 57,179 (94.95%)
had a high school education or above. Patients with less than high school
education were more likely to be female, of older age, have Medicare or
Medicaid, and be of Hispanic, Asian, or other race (table). Calculated
Flesch-Kincaid grade levels and Reading Ease scores for brochures were:
American Society of Transplantation: Getting a New Liver (6.2, 74.7), American
Liver Foundation (ALF) Liver Transplant (6.6, 71.9), National Institutes of
Health: What I Need to Know About Liver Transplantation (7.2, 67.5), American
Liver Society LT brochure (7.3, 67.3), and ALF Facts on Liver Transplantation
(11.4, 42.1).
Conclusions:
·
Most
LT patients have completed at least the eighth grade and are likely to
understand LT educational brochures.
·
However,
the LT evaluation process may exclude many patients with poor literacy skills,
and current brochures may be too advanced for those who are beginning to
consider LT.
·
Future
strategies for educating patients who are considering liver transplantation
will need to involve efforts to effectively provide information to patients
with poor literacy skills.
|
|
Less than high school |
High school or above |
p-value |
|
|
Gender (%) Male Female |
1702 (4.52) 1341 (5.95) |
35,987 (95.48) 21,192 (94.05) |
< 0.0001 |
|
|
Age (mean ± SD) |
53.03 ± 9.88 |
49.79 ± 10.16 |
< 0.0001 |
|
|
Race (%) White Black Hispanic Asian Other |
1436 (3.15) 151 (3.26) 127 (19.60) 179 (9.22) 1150 (15.57) |
44,176 (96.85) 4483 (96.74) 521 (80.40) 1762 (90.78) 6237 (84.43) |
< 0.0001 |
|
|
Primary Pay (%) Private Medicaid Medicare Other government Self Other |
1269 (3.15) 913 (10.83) 689 (8.29) 118 (5.41) 20 (4.21) 34 (5.96) |
38,983 (96.85) 7521 (89.71) 7621 (91.71) 2063 (94.59) 455 (95.79) 536 (94.04) |
< 0.0001 |
|
603. Long
Term Outcomes Of Liver Transplantation In A High-MELD Cohort
J. Lee; M. Lee; L. Shapiro; A. L. Yang; A. S. Lapasaran;
S. Parvez; A. Kamal; E. B. Keeffe; C. O. Esquivel; A. Ahmed
BACKGROUND:
MELD scores predict both pre-transplant and post-transplant
mortality. Diabetes mellitus has also been shown to predict post-transplant
mortality, but the relative importance of these two factors remains unknown.
METHODS:
We reviewed all adult liver transplants performed at our
institution between February 1995 and June 2006. Of 530 transplants performed,
information regarding MELD score and the presence or absence of diabetes was
available for 431. Patients with acute liver failure (n=17), those undergoing
kidney-liver transplant (n=28), and those who died prior to discharge (n=51)
were excluded. The remaining 370 patients were divided into four groups, based
on MELD score (<30 or ≥30) and the presence or absence of diabetes.
RESULTS:
As expected, survival was poorer in the high MELD group
(Log-rank statistic 23.2, p<0.001). However, patients with a MELD score ≥30
and without diabetes had a similar outcome as patients with a MELD score less
than 30 and with diabetes (Log-rank statistic 0.51, p =0.47). The outcome was
poor in patients with diabetes and MELD ≥30, but the observation in this
group was limited by a small sample size and needs to be studied further.
CONCLUSIONS:
Our results suggest that patients with MELD score ≥30
in the absence of diabetes have a favorable post-transplant outcome. The
presence or absence of diabetes appears to limit the reliability of MELD score
as an allocation system for liver transplantation and its ability to predict
post-transplant survival outcomes. Further validation studies are needed to
assess the impact of diabetes on MELD score.
|
|
MELD < 30 |
MELD ≥ 30 |
||
|
-DM |
+DM |
-DM |
+DM |
|
|
Number of Patients |
254 |
55 |
54 |
7 |
|
Mean Age (yr) |
50.1 |
54.4 |
47.8 |
51.3 |
|
Mean BMI (kg/m2) |
27.1 |
28.2 |
26.9 |
27.9 |
|
Hepatitis C (%) |
48 |
53 |
31 |
86 |
|
Overall Survival (%) |
95 |
82 |
89 |
71 |
|
Mean Follow-up (yr) |
4.99 |
3.88 |
3.38 |
1.49 |
611.
Development of a UK Score for Patients with End-stage Liver Disease
K. M. Barber; S. E. Pioli; J. E. Blackwell; D.
Collett; J. M. Neuberger; A. E. Gimson
Background:
Although the MELD score is widely used to predict mortality
on the liver transplant list, it has not been validated for use in the UK. A
score for UK patients with end-stage liver disease has therefore been
developed.
Methods:
The study cohort comprised adult elective patients registered
for their first liver transplant at the 7 UK centres between 1 April 2003 and
31 March 2006. Patients were followed-up until death, liver transplantation or
last known follow-up. Patients with any type of cancer recorded as their
primary liver disease were excluded. The resulting cohort comprised 1,103
patients. Cox proportional hazards models were used in modelling the hazard of
death on the list. The clinical components considered for inclusion in the UK
specific score, termed UKELD, were INR, serum creatinine, bilirubin and sodium,
and the UKELD score was expressed as a linear combination of the logarithms of
the clinical components. The UKELD score was compared to MELD and MELD-Na by
computing the change in the log likelihood (-2logL) statistic on adding each of
the three scores to a Cox model that included relevant patient-specific
factors. The UKELD score was validated using data from the 7 UK centres on
adult elective patients registered for their first liver transplant between 1
April 2006 and 31 March 2007. The resulting cohort comprised 452 patients. The
patients in the validation cohort were divided into 3 groups based on their
risk score, with patients having a high, medium and low score. The Kaplan-Meier
estimate of the survivor function for each group was then compared to the model
based estimates of the survivor function, adjusted for patient
specific-factors.
Results:
The UKELD score is calculated using the following formula:
UKELD=[(5.395xln(INR))+(1.485xln(creatinine))+(3.13xln(bilirubin))–(81.565xln(sodium))]+435
The results from the validation confirmed this score is an
appropriate measure of disease severity for UK patients. As UKELD increases the
risk of death on the transplant list also increases. UKELD was found to be a
superior predictor of mortality on the transplant list compared to MELD and
MELD-Na.
Conclusion:
The UKELD score is deemed appropriate to use to predict
mortality on the transplant list for UK patients with end-stage liver disease.
Patients with cancer and those with other variant diseases may need to be
awarded additional UKELD points to avoid disadvantaging them.
A. Taketomi; K. Sanefuji; T. Iguchi; H. Kayashima; N.
Harada; K. Sugimachi; Y. Yamashita; T. Ikegami; T. Yoshizumi; Y. Soejima; Y.
Maehara
Introduction:
The Milan criteria have been accepted as the selection
criteria for hepatocellular carcinoma (HCC) patients. However, many patients
who did not meet the Milan criteria have survived after undergoing living donor
liver transplantation (LDLT). As a result, different patient selection criteria
are thus considered to be necessary in LDLT in order to save as many
individuals as possible with advanced HCC.
Patients and Methods:
Of 214 adult-to-adult LDLT patients, 90 with concurrent HCC
were included in the study. The mean age of the patients was 56.8 years old
(range: 21 to 70). Sixty-five patients (72.2%) suffered from a hepatitis C
virus infection. The overall survival rates according to various factors were
compared to identify the risk factors for survival and to establish new
selection criteria for LDLT candidates for HCC.
Results:
Fifty-three patients (58.9%) preoperatively exceeded the
Milan criteria. The 1-, 3- and 5-year overall survival rates of the patients
who fulfilled the Milan criteria were 100%, 100%, and 100%, respectively,
whereas those for patients who exceeded the criteria were 85.5%, 68.2%, and
68.2%, respectively. In a multivariate analysis, both the tumor diameter
(p=0.0187) and the des-gamma-carboxy prothrombin value (DCP; p=0.026) were
found to be favorable independent factors of survival after LDLT. Therefore,
the authors devised new selection criteria for HCC patients (which are named
the KU criteria; a tumor diameter of less than 5 cm or a DCP of less than 300
mAU/ml). The 1-, 3- and 5-year overall or recurrence-free survival rates of the
85 patients who met the KU criteria were 92.1 / 85.2 / 85.2% or 90.6 / 87.1 /
87.1%, respectively, which were significantly different from those of the 5
patients who did not meet the KU criteria (80 / 20 / - % or 20 / 0 / 0 %; p<
0.0001).
Conclusions:
A combination of two factors, namely the tumor size and the
DCP level, was found to be useful for predicting survival after LDLT. These new
selection criteria (the KU criteria) might therefore be useful for expanding
the selection of LDLT candidates for HCC.
J. C. Lai; J. C. Emond; R. S. Brown
BACKGROUND:
The growing deficit of organs available for transplantation
warrants continued evaluation of the application of adult living donor liver
transplantation (LDLT). Several studies have reported the costs of deceased
donor liver transplantation (DDLT), but data regarding the costs of LDLT are
limited by including early experience, which is associated with increased
complication rates, and small sample sizes.
AIM:
To provide a comparison of transplant hospitalization costs
of LDLT vs DDLT after the initial experience. METHODS: This was a retrospective
cohort of consecutive patients who received liver transplants at our
institution from 1/1/00–12/31/06 for whom financial data were available. Our
primary outcome was cost, estimated from total charges of the transplant
hospitalization (converted into relative cost units), including donor charges
for LDLT. All charges were classified into cost categories, including: floor
services, diagnostics, laboratory, surgical, pharmacy, and other services. Our
independent variable was type of transplant (LDLT/DDLT). Covariates included
age, sex, race, insurance status, MELD, and length of stay (LOS). Any variable
associated with total costs (p<.2) in bivariate analysis was included in
multivariate analysis (MVA) with and without LOS as a covariate.
RESULTS:
This study included 469 patients (n=84 LDLT vs n=385 DDLT).
Baseline characteristics differed substantially between LDLT and DDLT,
including age (50 vs 54 yrs, respectively), %male (51% vs 74%), pre-transplant
MELD (20.6 vs 23), %white (62% vs 48%), %black (1% vs 12%), %Hispanic-white
(30% vs 18%), and %other (7% vs 22%). LOS and insurance status were similar.
Total charges for LDLT were 5% lower than for DDLT, but this was not
statistically significant (Table). Cost category analysis revealed increased
surgical charges for LDLT, but decreased charges for labs and pharmacy (Table).
In MVA, LDLT was similar in cost to DDLT after adjustment for age, black race,
private insurance, and MELD score, both with (p=0.53) and without (p=0.31)
adjustment for LOS. Age, MELD, and black race did predict higher cost.
CONCLUSION:
In a comparison of the financial costs of LDLT vs DDLT at an
experienced transplant center, overall transplant costs of LDLT were similar to
DDLT, despite increased surgical costs.
Table: Comparison of total and select cost category charges, in relative cost units
|
Description |
LDLT(n=84) |
DDLT(n=385) |
p value |
|
|
Total |
|
160,253 |
168,081 |
0.58 |
|
|
Surgical |
35,117 |
20,992 |
<0.01 |
|
Laboratory |
20,054 |
28,159 |
<0.01 |
|
|
Pharmacy |
12,594 |
23,272 |
<0.01 |
|
617.
Successful Algorithm for Selective Liver Biopsy in the Right Lobe Liver Donor
(RLD)
M. Simpson; J. E. Verbesey; U. Khettry; F. Gordon; J. J.
Pomposelli; R. L. Jenkins; E. A. Pomfret
Background.
Routine vs. selective pre-donation liver biopsy (LBx) remains
controversial for assuring the safety of RLD. We report the results of our
selective algorithm for LBx in RLD.
Methods.
Between 12/99 and 3/07, 380 potential RLD were evaluated and
131 donated. Indications for selective LBx were: abnormal liver function tests,
abnormalities noted on imaging studies, BMI>28, and a genetic relation to a
recipient with immune mediated liver disease. All donors had a LBx at the time
of surgery. The same pathologist reviewed all LBx.
Results.
Of the 380 potential RLD evaluated (53.9% male, mean age
37.6), 139(36.6%) were accepted as donors, 140(36.8%) were rejected for either
donor or recipient reasons, 68(17.9%) withdrew from the process, 23(6.1%) had
their recipient receive a deceased donor graft, and 10(2.6%) are currently
completing evaluation. 81(21.3%) met criteria and had a selective LBx. 7
results are still pending. 58(78.4%) had either normal (n=21) or mild
macrosteatosis of 0-5%(n=37) and 40 of these went on to LD right hepatectomy
(LDRH). 12 RLD were eliminated as donors as a result of abnormal LBx. Of the 89
who did not have LBx, none had abnormal liver histology at LDRH. 3/81 (3.7%)
had complications from the LBx resulting in overnight admission (2 for pain, 1
for bleeding, transfusion not required).
Conclusions:
Use of this algorithm for selective pre-donation LBx in the
RLD resulted in 78.7% of potential donors avoiding biopsy and potential
complications. No significant liver pathology was identified in donors not
meeting criteria for LBx. Routine pre-donation LBx is unnecessary in potential
RLD.
N. Yi; K. Suh; H. Lee; W. Shin; J. Yoon; K. Lee
Introduction
Adult living donor liver transplantation (ALDLT) had shown
comparable outcome to the deceased donor recipients because of being better
risk candidates. However, outcome of very ill patients with high MELD score is
fairly elusive especially in small grafts (< 0.8% of graft-to-recipient
weight ratio, GRWR) in ALDLT.
Methods
Between 1999 and 2005, consecutive 167 hepatitis B virus-infected
recipients underwent ALDLT at our center. Based on pre-transplant MELD,
recipients were stratified as low risk (≤25, Group L, n=105) and high
risk (>25, Group H, n=62). To analyze the risk of graft size in very ill
patients, patients were divided HR (high risk group; MELD score >25 and GRWR
< 0.8%), LR (low risk group; MELD >25 or GRWR <0.8%), and NR (no risk
group; MELD ≤25 and GRWR ≥ 0.8%) group. Primary end points were
one-year patient survival. Post-transplant follow-up was 32.6 months.
Results
Mean MELD scores were 17.1 in Group L and 32.6 in Group H. In
pre-transplant recipients’ dada, Group H more frequently had uncontrolled
ascites (50.0%), encephalopathy (64.5%), bacterial peritonitis (48.4%), and
UNOS status 2A (38.7%) than Group L (27.6%, 30.5%, 27.6% and 4.8%) (p<0.05). Accompanying hepatocellular carcinoma (HCC) was
more common in Group L (61.0%) than in Group H (22.6%) (p=0.000). Mean hospital
stay were 33 days in Group L and 47 days in Group H (p=0.000). One-year patient
survival rate (1-YSR) was 86.7% in Group L and 83.8% in Group H, respectively
(p=0.48). There was no significant difference in 1-YSR among HR (72.7%), LR
(84.6%), and NR (88.5%) group, respectively (p=0.278). Multivariate analysis
revealed accompanying HCC and early transplant year to be risk factors of with
poor 1-YSR (p<0.05).
Conclusion
·
In
summary, outcome including 1-YSR of Group H in ALDLT was similar to group
L. In subgroup analyses high risk group
had lower 6 mo survival than the others, but its 1-YSR was similar to the
others. In addition, accompanying HCC and the year of
transplant , but not MELD score (≥ 25) must not be excluded in ALDLT
candidates.
·
However,
during early post-transplant period critical care must be given if they had
small for size graphs.
·
Accumulation
of center’s experience may improve the early post-transplanted survival in very
ill patients in ALDLT.
621. Use of
Donation-after-Cardiac-Death (DCD) Donors for Combined Liver and Kidney
Transplantation
W. R. Hewitt; J. Stauffer; M. Mai; H. Grewal; L.
Arasi; B. Rosser; D. Kramer; J. Canabal; J. H. Nguyen; H. Wadei; N. Ahsan; D.
Willingham; A. Keaveny; J. Aranda-Michel; D. M. Harnois; R. Satyanarayana; R.
C. Dickson; T. Gonwa; C. B. Hughes
Renal failure is a common complication of end-stage liver
disease and is increasingly recognized among candidates for liver
transplantation (LT). Outcomes are clearly superior when such patients undergo
combined liver and kidney transplantation (LKT). However, this approach
increases the demand for kidney donors. Donation after cardiac death (DCD)
successfully expands the donor pool to provide isolated kidney and liver
allografts. We sought to investigate the outcomes after combined LKT with DCD
and non-DCD organs at our institution.
METHODS:
A retrospective review of all patients who received an LT at
our center from 04/2000 until 02/2007 was conducted. A total of 1361 LTs were
performed during that time. Of these, 39 (2.9%) had a LKT transplant, 9 received
DCD organs. Liver and kidney graft cold ischemia times (CIT) were recorded.
These patients were then analyzed and their outcome was compared to the 30
non-DCD LKT.
RESULTS:
In the LKT recipients 41.0% were diabetic, 48.7% required
renal replacement therapy (RRT) pre-transplant and 33.3% required RRT
post-operatively. None of the transplants utilized HBcAb-positive grafts and 1
non-DCD recipient received a HCV-Ab + graft. There was no significant
difference in patient characteristics or transplant outcomes other than initial
hospital length of stay (LOS).*
The one-year patient survival for DCD LKT was 88.9% compared
to 83.3% with non-DCD LKT. The one-year liver and kidney graft survival for the
DCD group was 77.8% and 88.9%, respectively. Glomerular Filtration Rate at one
year after LKT was 55.0 ± 30.4 and 46.8 ± 18.3 ml/min for non-DCD (n=20) and
DCD (n=4) grafts, respectively.
CONCLUSION:
The use of DCD organs for solitary liver transplant or
solitary kidney transplant is well described. The combination of the two has
not been well defined. Despite the higher incidence of need for RRT and longer
hospital stay the utilization of DCD donors provides comparable graft and
patient survival and should be considered for patients requiring combined liver
and kidney transplants.
Pt Characteristics
|
|
DCD (n=9) |
non-DCD (n=30) |
p-value |
|
Age at Tx (yrs) |
56.3 ± 10.2 |
55.3 ± 8.9 |
0.77 |
|
Donor Age (yrs) |
32.4 ± 13.4 |
34.9 ± 16.4 |
0.68 |
|
MELD |
25.2 ± 6.7 |
22.4 ± 6.2 |
0.24 |
|
RRT post-Tx |
5 (56%) |
8 (27%) |
0.11 |
|
Liver CIT (hr) |
6.27 ± 1.4 |
7.0 ± 1.3 |
0.18 |
|
Kidney CIT (hr) |
8.2 ± 2.3 |
9.7 ± 1.9 |
0.06 |
|
LOS (d) |
23.1 ± 14.3 |
12.7 ± 9.6 |
0.02* |
E. T. Castaldo; R. T. Russell; I. D. Feurer; C.
Pinson
Introduction:
With minimal existing data our primary aim was to correlate
the model for end-stage liver disease (MELD) score pretransplant and quality of
life after liver transplantation (LT).
Methods:
A single institution prospective study of all patients
undergoing first time LT over a 4-year period was conducted. Patients were
given the SF-36 at 1, 3, 6, or 12 months post-LT. MELD was calculated the day
of LT. Simultaneous multiple regression-based path analysis was used to test
the effects of MELD, diabetes, diagnosis, length of stay (LOS), time post-LT,
rejection, and the contemporaneous Karnofsky performance score (KPS), on the
physical component (PCS) and mental component (MCS) summary scales of the
SF-36.
Results:
There were 209 participants. Diabetes, LOS, and rejection
were associated with worse KPS (p≤0.02) whereas time post-LT was
associated with an improved KPS (p<0.01). Factors influencing quality of
life measured by PCS and MCS of the SF-36 are shown in the table.
Conclusions:
Increasing MELD score was associated with improvement in PCS.
MELD did not affect MCS. Functional performance, measured by KPS, had the
largest effects on post-LT quality of life. Since good quality of life can be
expected even with higher MELD scores, they should not discourage
transplantation.
Factors Influencing Quality of Life
|
Variable |
PCS |
MCS |
|
MELD |
β=0.16, p=0.01 |
NS |
|
Diabetes |
NS |
NS |
|
Cholestatic Cirrhosis |
β=0.12, p=0.05 |
NS |