The MELD score predicts the short-term and overall survival after liver transplantation in patients with primary sclerosing cholangitis or autoimmune liver diseases.

PURPOSE: Liver transplantation (LT) is well established in patients with autoimmune liver disease. Despite excellent outcomes, organ scarcity demands careful patients' selection and timing of transplantation. METHODS: This retrospective study analyzes data of 79 consecutive patients with primary sclerosing cholangitis (PSC), autoimmune hepatitis (AIH), and overlap syndrome, undergoing LT between 2001 and 2012. Overall survival (OS) and graft survival were assessed using Kaplan-Meier estimate. Multivariate survival analysis was performed to identify prognostic factors by using Cox regression model. RESULTS: After 59.6-month median follow-up, the 5-year OS and graft survival were 75.3 and 68.8%, respectively. The 5-year survival rates for patients with PSC (n=57), AIH (n=17), and overlap syndrome (n=5) were 76.3, 76.0, and 60.0%. The 90-day mortality rate of 70.0% was significantly higher in patients with a labMELD score≥20 (n=10) compared to 26.1% in 69 patients with a labMELD<20 (p=0.009). A lab Model for End-Stage Liver Disease (MELD) score≥20 was an independent predictor of impaired OS (p=0.050, hazard ratio 2.5). The 5-year OS was 55.7% in patients with a labMELD score≥20 compared to 84.7% in patients with a labMELD score<20. CONCLUSION: The recipients' MELD score is a predictor for the short-term outcome after LT in patients with autoimmune liver disease. Meticulous selection for transplant listing remains necessary to safe scarce donor organs.

Prediction of postoperative mortality in liver transplantation in the era of MELD-based liver allocation: a multivariate analysis.

BACKGROUND AND AIMS: Liver transplantation is the only curative treatment for end-stage liver disease. While waiting list mortality can be predicted by the MELD-score, reliable scoring systems for the postoperative period do not exist. This study's objective was to identify risk factors that contribute to postoperative mortality. METHODS: Between December 2006 and March 2011, 429 patients underwent liver transplantation in our department. Risk factors for postoperative mortality in 266 consecutive liver transplantations were identified using univariate and multivariate analyses. Patients who were <18 years, HU-listings, and split-, living related, combined or re-transplantations were excluded from the analysis. The correlation between number of risk factors and mortality was analyzed. RESULTS: A labMELD ≥20, female sex, coronary heart disease, donor risk index >1.5 and donor Na+>145 mmol/L were identified to be independent predictive factors for postoperative mortality. With increasing number of these risk-factors, postoperative 90-day and 1-year mortality increased (0-1: 0 and 0%; 2: 2.9 and 17.4%; 3: 5.6 and 16.8%; 4: 22.2 and 33.3%; 5-6: 60.9 and 66.2%). CONCLUSIONS: In this analysis, a simple score was derived that adequately identified patients at risk after liver transplantation. Opening a discussion on the inclusion of these parameters in the process of organ allocation may be a worthwhile venture.

LabMELD-based organ allocation increases total costs of liver transplantation: a single-center experience.

INTRODUCTION: In 2006, model for end-stage liver disease (MELD)-based allocation was implemented in the Eurotransplant (ET) region. Sick patients, who in general require more resources, are prioritized. In this analysis, the effect of MELD on costs for liver transplantation (LTx) was assessed. METHODS: Total costs for LTx before and after implementation of MELD were identified in 256 patients from January 2005-December 2007. Forty-nine patients (Re-LTx, HU listings, and 30-d mortality) were excluded from further analysis. The costs of LTx in 207 patients have been correlated with their corresponding labMELD; 84 and 123 LTx before and after implementation of MELD were compared, and patient survival was monitored. RESULTS: A positive correlation exists between labMELD and costs (r(2) = 0.28; p < 0.05). Only nominal correlation existed between the Child-Pugh classification and costs. The labMELD scores can be stratified into four groups (I: 6-10, II: 11-18, III: 19-24, and IV: >24), with an increase of €15.672 ± 2.233 between each group (p < 0.05). Recipients' labMELD at the time of LTx increased significantly in the MELD-based allocation system. Costs increased by €11.650/patient (p < 0.05), while median survival decreased from 1219 to 869 d (p < 0.05). CONCLUSION: LabMELD-based allocation increased total costs of LTx. In accordance with other studies, the sickest patients need the most resources.

Risk factors of survival after liver transplantation for HCC: a multivariate single-center analysis.

BACKGROUND: The selection criteria for liver transplantation (LT) in patients with hepatocellular cancer (HCC) are well defined. Increasing evidence suggests that the effectiveness of pre-transplant bridging influences the individual course after LT significantly. Thus, the aim of this study was to determine its impact on tumor progression during waiting time and identify patient subgroups with favorable oncological long-term outcome. METHODS: Prospectively collected data of 78 consecutive patients undergoing LT for HCC between 2001 and 2007 were analyzed retrospectively. Survival rates were assessed using the Kaplan-Meier estimate. Clinicopathologic prognostic factors were identified by Cox regression analysis. RESULTS: After 48.9 months of median follow-up, the five-yr overall survival rate is 57% with a five-yr recurrence-free survival rate of 74%. Progressive disease (PD) during bridging was developed in 32% of patients, and a trend toward impaired overall survival in patients with PD before LT was detected in multivariate analysis (p = 0.073). HCC ≥3 cm was associated with a three times increased risk of recurrent disease. Neither fulfillment of MILAN criteria nor bridging with transarterial chemoembolization had an impact on the outcome. CONCLUSION: PD during waiting time influences the oncological course after LT. However, even with an increasing organ shortage, further studies are warranted to define clear selection criteria based on the biological tumor behavior and allow a more personalized treatment.

A single-center experience of 500 liver transplants using the modified piggyback technique by Belghiti.

Over the past 4 decades, the surgical techniques of liver transplantation (LTx) have permanently evolved and been modified. Among these, the modified piggyback (MPB) technique by Belghiti offers specific advantages. The objective of this study was to present our single-center experience with the MPB technique in 500 cases. Recipients' perioperative data were prospectively collected and evaluated. Postoperative and specific complications, stay in the intensive and intermediate care unit, and the mortality rate with cause of death were analyzed. Most recipients were classified as Child C (49.1%). For the patients who underwent LTx for the first time, alcoholic (23.9%) and viral (22.2%) cirrhosis and hepatocellular carcinoma (15.1%) were the prevalent indications. The overall median warm ischemia time, anastomosis duration, and operative time were 45, 108, and 320 minutes, respectively. The median intraoperative blood loss was 1500 mL. A venovenous bypass was never needed to maintain hemodynamic stability. Only in a few cases was temporary inferior vena cava clamping necessary. Most prominent surgical complications were hemorrhage, hematoma, and wound dehiscence. Renal failure occurred in 6.2% of patients. The overall median stay in the intensive and intermediate care unit was 14 days. The mortality rates within 30 and 90 days were 6.3% and 13.3%, respectively. No technique-related death occurred. The MPB technique by Belghiti is a feasible and simple LTx technique. The caval flow is preserved during the anhepatic phase, and this minimizes the need for venovenous bypass or portocaval shunt. This technique requires only 1 caval anastomosis, which is easy to perform with a short anhepatic phase. To minimize the risk of outflow obstruction, attention should be paid by doing a wide cavocavostomy cranially to the donor inferior vena cava in a door-lock manner. This technique can be applied in almost all patients undergoing LTx for the first time and liver retransplantation as well.

Is veno-venous bypass still needed during liver transplantation? A review of the literature.

Orthotopic liver transplantation has been made feasible with intra-operative femoral-to-jugular veno-venous bypass (VVB) to redirect the blood from the lower extremities and the kidneys to the heart. This reduces hemodynamic instability and metabolic disturbances. However, complications such as thromboses with pulmonary thrombembolism or post-reperfusion syndrome were observed in up to 30% of the cases. The latter, recent developments of cava-sparing surgical techniques, shorter anhepatic times plus optimized anesthetic management have made the necessity for a routine use of VVB questionable.