Prognostic Factors in Patients With Acute Liver Failure Undergoing Live Donor Liver Transplantation

doi:10.1016/j.transproceed.2008.07.009

Transplantation Proceedings

Volume 40, Issue 8, October 2008, Pages 2492-2493

https://doi.org/10.1016/j.transproceed.2008.07.009 Get rights and content

Abstract

Mortality from acute liver failure (ALF) is high. Live donor liver transplantation (LDLT) is the treatment of choice for ALF in Asia, because cadaveric donors are rare. We sought to review our results in ALF patients with undergoing LDLT at our center. One hundred two LDLTs were performed at our center from April 2002 to November 2007, 15 (14%) because of ALF. Mean (SEM; median, range) follow-up was 1,065 (189; 1400; 3–2046) days. Nine patients (60%) had acute exacerbation of chronic hepatitis B; and 6 (40%) had drug-induced liver injury. Age was 47 (3; 50; 27–65) years. Ten patients (67%) were men. At transplantation, laboratory values were included bilirubin, 449 (35) μmol/L; creatinine concentration, 182 (32) mmol/L. The international normalized ratio was 2.4 (0.2). The Model for End-Stage Liver Disease (MELD) score was 34 (2). Both inpatient and long-term mortality was 20% 3 of 15 patients died. The 5-year survival was 80%. Compared with survivors, patients who died had a significantly higher creatinine concentration 289 vs 155 μmol/L, international normalized ratio (3.4 vs 2.1), MELD score (47 vs 32). We conclude that despite being sick with median and mean MELD scores of 32 and 34, 80% of patients with ALF can achieve good long-term survival after LDLT.

Section snippets

Methods

We reviewed the medical records for all patients with ALF who underwent LDLT at our center from 2002 to November 2007. Data for survivors and nonsurvivors were compared using univariate analysis. Categorical variables were evaluated using the Fisher exact test, and continuous variables were compared using the Kruskal-Wallis test. P < .05 was considered statistically significant. Multivariate analysis was not performed because the number of subjects was small. All data were analyzed using

Results

Over the last 6 years, 102 LDLTs were performed at our center, including 15 (14.7%) in patients with ALF. Nine patients (60%) had acute exacerbation of chronic hepatitis B, and 6 (40%) had drug-induced liver injury, age was 50 (27–65 years). Ten patients (67%) were men. Follow-up was 1401 (3–2046) days. At transplantation, 5 patients (33%) were receiving ventilatory support and 7 (47%) were receiving hemodialysis or liver dialysis with the molecular adsorbent recirculating system (MARS; Gambro

Discussion

Our study showed that despite being sick with high MELD scores of up to 42, patients with ALF achieved 80% long-term survival after LDLT. The only 3 deaths were in patients with ALF with high MELD scores of 45, 46, and 48.

Our study also showed an excellent long-term prognosis among those who survived the immediate posttransplantation period. This is not surprising because significant posttransplantation mortality was often related to recurrence of the primary liver disease. It is unlikely that

References (7)

G. Ostapowicz et al.
Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States
Ann Intern Med
(2002)
C.T. Wai et al.
Clinical outcome and virological characteristics of hepatitis B–related acute liver failure in the United States
J Viral Hepatol
(2005)
C.T. Wai et al.
MARS: a futile tool in centres without active liver transplant support
Liver Int
(2007)

There are more references available in the full text version of this article.

Cited by (8)

Prognostic Factors Predicting Poor Outcome in Living-Donor Liver Transplantation for Fulminant Hepatic Failure
2017, Transplantation Proceedings
Citation Excerpt :
The patients who survived the immediate post-LT period also showed long-term survival without death until recently. This is because significant post-LT mortality was often related to recurrence of primary liver disease, and most patients with toxic hepatitis avoid taking the offending medication [11]. Taken together, LDLT is feasible as a life-saving treatment for patients with irreversible FHF.
Living-donor liver transplantation (LDLT) has been accepted as feasible treatment for fulminant hepatic failure (FHF), although it has generated several debatable issues. In this study, we investigated the prognostic factors predicting fatal outcome after LDLT for FHF.
From April 1999 to April 2011, 60 patients underwent LT for acute liver failure, including 42 patients for FHF at Samsung Medical Center, Seoul, Korea. Among 42 patients, 30 patients underwent LDLT for FHF, and the database of these patients was analyzed retrospectively to investigate the prognostic factors after LDLT for FHF.
Among 30 patients, 7 patients (23%) died during the in-hospital period within 6 months, and 23 patients (77%) survived until recently. In univariate analyses, donor age (>35 years), graft volume (GV)/standard liver volume (SLV) (<50%), cold ischemic time (>120 minutes), hepatic encephalopathy (grade IV), hepato-renal syndrome (HRS), and history of ventilator care were associated with fatal outcome after LDLT for FHF. In multivariate analyses, HRS, GV/SLV (<50%), and donor age (>35 years) were significantly associated with fatal outcome. Although the statistical significance was not shown in this analysis (P = .059), hepatic encephalopathy grade IV also appears to be a risk factor predicting fatal outcome.
The survival of patients with FHF undergoing LDLT was comparable to that in published data. In this study, HRS, GV/SLV <50%, and donor age >35 years are the independent poor prognostic factors.
Intraoperative predictors of short-term mortality in living donor liver transplantation due to acute liver failure
2013, Transplantation Proceedings
Citation Excerpt :
The accuracy and reproducibility of the KCC7 and Clichy criteria27 are not perfect.28 Accordingly, modified criteria or new systems, such as MELD scores or ICU severity scales, have been tested as prognostic indicators.9,29,30 In our study, a MELD score (≥30 points) was incorporated into the prediction model for posttransplant mortality, but its clinical utility was limited because of the high false-positive rate that was identified among paracetamol-induced ALF.9
Acute liver failure (ALF) is a rare and fatal disease with rapidly deteriorating clinical features. Many predictive models for ALF outcomes have been tested, but none have been adopted as definitive guidelines for prognosis because of inconsistencies in accuracy. Most prognostic models for ALF are based on preoperative patient conditions, thus ignoring various specific intraoperative features relevant to postoperative outcomes. We investigated whether intraoperative factors predicted short-term mortality due to ALF in living donor liver transplantations (LDLT).
We retrospectively collected intraoperative data, including surgical time, fluctuations in mean blood pressure (MBP) and heart rate, mean pulmonary arterial pressure (PAP), central venous pressure (CVP), urine output, laboratory data, oxygen indices (PaO₂/FiO₂), administered drugs, and transfusion of packed red blood cells (PRBCs) from 101 patients with ALF who underwent LDLT. After simple relationships of individual intraoperative variables with 1-month posttransplant mortality were analyzed, we examined potentially significant intraoperative variables (P < .10) by a multivariate adjustment process with preoperative indicators of ALF prognosis.
Intraoperative MBP fluctuations, first mean PAP and CVP, last oxygen index, administered calcium chloride, and PRBC transfusion showed individual associations with posttransplant mortality of ALF patients (P < .05). After multivariate adjustment, PRBC transfusion of ≥10 pints (odds ratio 4.73; 95% confidence interval [CI] 1.06–21.16) and MBP fluctuations (odds ratio 1.26; 95% CI 1.00–1.58) were identified to be independent predictors of 1-month posttransplant mortality, together with preoperative factors, including severe hepatic encephalopathy, and a Model for End-stage Liver Disease score ≥30 points (area under the curve 0.82, P < .001).
MBP fluctuations and large blood transfusions were intraoperative predictors of short-term mortality after LDLT due to ALF. Increased attention to intraoperative manifestations should provide valuable prognostic information for ALF.
Pretransplant model for end-stage liver disease score has no impact on posttransplant survival in living donor liver transplantation
2012, Transplantation Proceedings
Citation Excerpt :
Our analysis excluded patients with hepatocellular carcinoma, as its recurrence may be a confounding factor for long-term posttransplant survival.7 We also excluded patients with acute liver failure, as we have showed previously that those patients show better posttransplant survival than subjects with decompensated liver cirrhosis.8 At our center, patients were given a transplant package whereby the transplant recipients are allowed to stay up to 28 days after the procedure.
A high Model For End-stage Liver Disease (MELD) score ≥ 25 has been reported to be associated with increased posttransplant mortality and morbidity among patients undergoing living donor liver transplantation (LDLT). We reviewed the results of patients undergoing LDLT at our transplant center for decompensated cirrhosis to determine whether a high MELD impacted posttransplant survival.
From April 2002 to May 2011, 86–176 patients (49%) who underwent LDLT at our center had the indication of decompensated cirrhosis without hepatocellular carcinoma. Data were expressed in mean values ± standard error of the means (range). Patients survival rates were analyzed using Kaplan-Meier method.
Among the 86 patients with decompensated cirrhosis: Age was 49 ± 2 (1–68) years and 60 (70%) were of male gender. The causes in 25 (29%) were hepatitis B and 25 (29%) hepatitis C as well as one each for hepatitis B/C and B/D coinfections: 9 (10%), alcoholic cirrhosis. MELD score was 18 ± 1 (range = 6–40). In hospital mortality was 6/86 (7%). At 1152 ± 95 (range = 7–3317) days posttransplant follow-up 64 (74%) were alive with 1-, 3-, and 5-year survival rates of 84%, 70%, and 70%, respectively. MELD scores did not differ between those who survived and those who died (17.5 ± 8.0 versus 17.8 ± 8.4). No difference was noted in those with MELD < 25 or ≥25. In fact, the recipient with the highest MELD score (40) survived.
A high MELD score had no impact on posttransplant survival among cirrhotic patients undergoing LDLT. It should be considered to be an urgent indication rather than a contraindication to LDLT.
Pediatric acute liver failure in Brazil: Is living donor liver transplantation the best choice for treatment?
2016, Liver Transplantation
Severe hepatic necrosis of unknown causes following ABO-incompatible liver transplantation
2013, World Journal of Gastroenterology
Adult-to-adult living donor liver transplantation for acute liver failure in China
2012, World Journal of Gastroenterology

View all citing articles on Scopus

View full text

Liver transplantationOutcomePrognostic Factors in Patients With Acute Liver Failure Undergoing Live Donor Liver Transplantation

Abstract

Section snippets

Methods

Results

Discussion

Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States

Ann Intern Med

Clinical outcome and virological characteristics of hepatitis B–related acute liver failure in the United States

J Viral Hepatol

MARS: a futile tool in centres without active liver transplant support

Liver Int

Liver transplantation
Outcome
Prognostic Factors in Patients With Acute Liver Failure Undergoing Live Donor Liver Transplantation