Results of liver transplants from donors aged 70 plus: analysis of Andalusian transplant register.

The progressive increase in the number of liver transplantation candidates has brought with it a consequent increase in waiting list mortality, making it necessary to revise donor selection criteria and to analyze the factors that optimize outcomes. This retrospective observational study of 1802 liver transplantations performed in Andalusia between 2000 and 2010 analyzes the outcomes from donors aged 70 years or older (n = 211) in terms of survival rates of the graft and the recipient, the type of transplant, donor age, and DMELD (Donor-Model for End-Stage Liver Disease) score. The most frequent reasons for transplantation were alcoholic cirrhosis (45.5%), hepatitis C cirrhosis (20.4%), and liver cancer (11.8%). The overall survival rate at 5 years was 67%; with a significant decrease in survival rates for recipients with a DMELD greater than 1400 (44%). In the 70-year-old-plus donor group, the overall patient and graft survival rates were 57% and 52%, respectively. The re-transplantation rate increased proportionately with donor age: 5.9% between 70 and 74 years, 9.5% from 75 to 79 years, and 17.6% from 80 to 84 years. In the alcoholic cirrhosis recipient sub-group, the overall survival rate at 5 years was 69% (P < .05) compared to 34% in hepatitis C patients (P < .05). The widening of the donor age selection criteria is therefore a safe option, provided that a DMELD score less than 1400 is obtained. Although re-transplantation rates increase progressively with donor age, they remain less than 10%. It is necessary to carefully screen recipients of older organs, taking into account that the best results are obtained for patients who have alcoholic cirrhosis, are hepatitis C negative, and have a DMELD score that is less than 1,400.

Have we changed the liver retransplantation survival?

INTRODUCTION: Orthotropic liver retransplantation (RT) is the therapeutic option for the failure of an allograft. Patient and graft survival rates after RT are inferior to primary liver transplantation (OLT). Because of the limited number of donors, it is essential that we optimize their use. We reviewed 68 consecutive retransplantations to evaluate their results. MATERIALS AND METHODS: Using registry data from our Liver Transplantation Unit, we performed a retrospective cohort study of adult RT between 1991 and 2010. Patients were divided into 2 groups (urgent vs elective RT) to compare the utility of RT. We also analyzed data collected at the time of RT, including age, gender, indications for primary OLT and RT (hepatitis C virus [HCV]+ and HCV-). At various stages (1991-2000, 2001-2006, and 2007-2010), we calculated probability survival curves according to the Kaplan-Meier method with comparisons using the log-rank test. RESULTS: Among 771 adult liver transplantations, 68 (8.8%) underwent late secondary OLT. 21 (31%) cases were urgent and 47 elective RT (69%). Vascular complications was the most common cause for urgent RT, and chronic rejection, for elective RT. Differences were also detected in the overall survival of RT patients; mortality was significantly lower among the urgent procedures (15% vs 47.8%). Significantly differences were also detected in overall survival for RT patients between 2007 and 2010 (81.7% with urgent RT and 76.5% with elective situations). CONCLUSION: These data confirmed the utility of RT in elective and emergency situations. Overall survival of elective RT patients has improved in recent years. Liver RT requires a multidisciplinary team to decide the inclusion and prioritization of elective RT cases on the OLT waiting list.

Indications for and survival after liver retransplantation.

INTRODUCTION: Orthotopic liver retransplantation (re-OLT) is the therapeutic option for hepatic graft failures. Survival after re-OLT is poorer than after primary OLT. Given that there is an organ shortage, it is essential that we optimize our use of this scarce resource. We evaluated the results of re-OLT among 58 consecutive Re-OLT. MATERIALS AND METHODS: Using registry data from our Liver Transplantation Unit, we performed a retrospective cohort study of adult urgent versus elective re-OLT between 1991 and 2008. We recorded the indications for the initial OLT, and the intervals from OLT to re-OLT as well as age and gender. Using the Rosen model to stratify patients into low-intermediate-, and high-risk groups we calculated survivals. RESULTS: Among 661 adult liver transplantations, 56 patients (8.4%) underwent late re-OLT at a median of 654.4 days post-OLT. There were 17 (29%) urgent re-OLT and 41 elective cases (71%). Vascular complications were the most common cause of urgent re-OLT (64%); elective re-OLT was primarily due to chronic rejection (56.1%). Overall survival for retransplanted patients was significantly lower among urgent procedures (82.4% vs 48.8%), as well as for overall survival after re-OLT for patients with hepatitis C virus (HCV) versus other etiologies. CONCLUSION: These data confirmed the utility of retransplantation in elective and emergency situations. Liver re-transplantation has a high morbidity and mortality. It requires multidisciplinary experience to decide inclusion and prioritization criteria for re-OLT, especially among patients with HCV.

Rescue immunosuppression with mammalian target of rapamycin inhibitor drugs in liver transplantation.

BACKGROUND: Mammalian target of rapamycin (mTOR) inhibitors behave as potent immunosuppressants, which have the advantages, with respect to calcineurin inhibitors (CNI; cyclosporine or tacrolimus), of no nephrotoxicity but inhibition of cell proliferation. They are particularly suitable for patients with renal insufficiency or neoplasias. MATERIALS AND METHODS: Twenty-eight liver transplant patients were immunosuppressed with everolimus or sirolimus as rescue therapy after CNI treatment: 8 hepatocellular carcinomas; 7 de novo malignancies; 6 renal insufficiencies; 3 chronic rejections; 3 acute rejection episodes; and 1 epilepsy. RESULTS: There were 0% tumor recurrences, 50% improvements in 33% no change, and 17% worsening of renal function among cases of renal insufficiency; 0% improvement in cases of chronic rejection, and 33% improvement in acute rejection episodes. There was a 7% incidence of acute rejection episodes, but no kidney failure, gastrointestinal intolerance, hydrocarbon intolerance, hypertension, or arterial or venous thrombosis. Diarrhea occurred in 7%; hypercholesterolemi in 46% hypertriglyceridemia in 50% thrombocytopenia in 14%, leukopenia in 14%, and anemia in 39%. The 12% intercurrent infection rate included oral thrush in 11%. Lower limb edema occurred in 21%; 1 case displayed facial edema and 1, alopecia. CONCLUSIONS: mTOR inhibitors were safe immunosuppressive drugs whose side effects were controlled and easily managed. They have advantages with respect to CNI due to their slight effects on kidney function and lack of promotion of diabetes mellitus. Although their long-term effectiveness for control of neoplastic diseases is yet to be seen, they can be used safely in these patients with a low incidence of rejection. Their effectiveness to control steroid-resistant acute rejection episodes or renal insufficiency seems significant, but they are of doubtful benefit for chronic rejection.

Outcomes of domino liver transplantation: a single institution's experience.

AIMS: Domino liver transplantation (DLT) is a strategy to increase the donor pool. Explanted liver from patients with familial amyloidotic polyneuropathy (FAP) are often used as domino grafts, because the liver is normal apart from the production of the mutated transthyretin variant. We present the outcomes for both donors and recipients of DLT. MATERIALS AND METHODS: Retrospective analysis of initial DLT for 16 consecutive adult patients performed between July 2004 and July 2009. All cases of FAP donor to grafts were removed preserving the cava vein with reconstruction of the hepatic veins, except the first and seventh cases, where in we removed the retrohepatic vena cava with the liver without venovenous bypass. The postoperative follow-up period for surviving DLT recipients at the end of September 2009 was 2-62 months (mean, 26). RESULTS: Two patients out of 8 FAP donors died due to pulmonary thromboembolism on the 31st postransplant day, or sepsis at 35 days namely, an overall survival of 75%. One patient out of 8 recipients died namely, an early portal thrombosis on the 22nd postransplant day) with a crude survival of 87.5% in the recipient group (P = no significant [NS]). Four grafts from 8 FAP donors were lost-2 deaths and 2 retransplants due to thrombotic events on the first and second postransplant day-with a crude survival of 50%. Two of 8 recipients lost their grafts: 1 death and 1 retransplantation for an acute Budd-Chiari syndrome on the first postransplant day with a crude survival of 75% in the recipient group (P = not significant [NS]). CONCLUSION: We believe that the FAP liver graft is an excellent option for selected patients. Special care must be taken with thrombotic events.