Benedikt Reichert

The Donor-Risk-Index, ECD-Score and D-MELD-Score all fail to predict short-term outcome after liver transplantation with acceptable sensitivity and specificity

BACKGROUND Expansion of the donor pool by the use of grafts with extended donor criteria reduces waiting list mortality with an increased risk for graft and patient survival after liver transplantation. This study investigates the ability of the Donor-Risk-Index (DRI), the Extended-Criteria-Donor-Score (ECD-score) and the D-MELD-score to predict early outcome after liver transplantation. MATERIAL/METHODS 291 consecutive adult liver transplants (01.01.2007-31.12.2010) were analysed in a single centre study with ongoing data collection. Primary study endpoints were 30-day mortality, 3-month mortality, 3-month patient and graft survival and the necessity of acute retransplantation within 30 days. For the primary study endpoints ROC-curve analysis was performed to calculate the sensitivity, specificity, and overall model correctness of the Donor-Risk-Index (DRI), Extended-Criteria-Donor-Score (ECD-score) and the D-MELD-Score as predictive models. Cut-off values were selected with the best Youden index. RESULTS ROC-curve analysis showed areas under the curve (AUROCs) <0.7 for the DRI, the ECD-Score and the D-MELD-Score as models for the prediction of 30-day mortality, 3-month mortality, 3-month patient survival, 3-month graft survival as well as the necessity of acute retransplantation within 30 days after transplantation with unacceptable low levels of overall model correctness (<62%) and specificity (<56%). CONCLUSIONS The DRI, the ECD-Score and the D-MELD-Score all fail to predict short-term outcome after liver transplantation with acceptable overall model correctness in a current European transplant setting.

Endoscopic Endoluminal Vacuum Therapy in Esophageal Perforation

BACKGROUND Esophageal perforation is a serious disease with a high morbidity and mortality rate. Endoscopic vacuum therapy (EVT) is a new endoscopic treatment option, which is used to treat anastomotic leakages after rectal and esophageal resections. We report on 10 patients treated with EVT for esophageal perforation. METHODS Clinical and therapy-related data such as age, sex, duration of intensive care stay, length of hospital stay, reasons for perforation, EVT-associated complications, mortality, need for alternative treatment options, and course of infectious variables were analyzed. RESULTS Ten patients were treated with 54 vacuum sponges that were placed in upper gastrointestinal defects. Causes for perforation were iatrogenic, spontaneous, or foreign body-associated. Mean number of sponge insertions was 5.4 (range, 2 to 12) with a mean period of 19 ± 14.26 days. Successful therapy was achieved in 9 of 10 patients. After successful primary treatment, 1 patient died during therapy as a result of general failure of the cardiovascular system. In 1 patient, surgical resection was necessary after repeated Mallory-Weiss lesions and minor perforations during the course of immunosuppressive therapy. In a third patient an endoscopic stent was inserted in the clean wound cavity after primary EVT. CONCLUSIONS In this small trial EVT has been shown to be a safe and feasible therapy option for perforations of the upper gastrointestinal tract. If necessary, EVT can be combined with operative revision for better control of the local septic focus or used as a bridging procedure for wound conditioning before aggressive surgical treatment.

Value of the SOFA score as a predictive model for short-term survival in high-risk liver transplant recipients with a pre-transplant labMELD score ≥30

IntroductionThe Sequential Organ Failure Assessment (SOFA) score has been applied for the prediction of survival in critically ill patients. We analysed the value of the SOFA score for the prediction of short-term survival after liver transplantation in high-risk liver transplant recipients with a labMELD score ≥30.Patients and methodsWe conducted a retrospective single-centre analysis including 88 consecutive liver transplants in adults between January 1, 2007 and December 31, 2010 with a pre-transplant labMELD score ≥30. The SOFA score was assessed preoperatively, directly after transplantation and on post-operative days (PODs) 1–10. Combined and living-related liver transplants were excluded. Receiver operating characteristic (ROC) curve analysis with the Hosmer–Lemeshow test and application of the Brier score were used to calculate sensitivity, specificity, overall model correctness and calibration. Cutoff values were selected with the best Youden index.ResultsROC curve analysis showed areas under the curve (AUROCs) >0.8 for the SOFA score on PODs 1–10 for the prediction of hospital mortality, 30-day mortality and 3-month mortality with Hosmer–Lemeshow test results that confirmed good model calibration (p > 0.05). The Brier score demonstrated an accuracy of prediction (<0.25) of hospital mortality, 30-day mortality and 3-month mortality for the SOFA scores on PODs 4–9 indicating superior accuracy on PODs 7 and 8 with cutoff values for the SOFA score between 16.5 and 18.5. The pre-transplant SOFA score failed to reach AUROCs >0.7 (0.603–0.663) for the prediction of short-term survival.ConclusionsOur results confirm the usefulness of the SOFA score in high-risk liver recipients during the early post-operative course, especially on PODs 7–8 for the prediction of hospital mortality, 30-day mortality and 3-month mortality and may be useful to predict futile early acute retransplantation.

Value of the preoperative SOFT-score, P-SOFT-score, SALT-score and labMELD-score for the prediction of short-term patient and graft survival of high-risk liver transplant recipients with a pre-transplant labMELD-score ≥30

BACKGROUND The SOFT-score, P-SOFT-score, SALT-score and labMELD-score have been applied for the prediction of survival of liver transplant recipients after transplantation. We analysed the value of these scores for the prediction of short-term survival in high-risk liver transplant recipients with a labMELD-score ≥30. MATERIAL/METHODS Retrospective single-centre analysis including 88 consecutive liver transplants in adults between 01.01.2007 and 31.12.2010 with a pretransplant labMELD-score ≥30 and follow-up until the 31.12.2011. Combined and living-related liver transplants were excluded. ROC-curve analysis was used to calculate sensitivity, specificity and overall model correctness of prognostic models. RESULTS The P-SOFT-score demonstrated a significant influence on 1-year patient survival (p=0.045, Mann-Whitney-U test). Multivariate Cox regression analysis showed a significant influence of the P-SOFT-score on patient (p=0.013; Exp(B)=1.050; 95%CI: 1.010-1.091) and on graft survival (p=0.023; Exp(B)=1.042; 95%CI: 1.006-1.080). ROC-curve analysis showed areas under the curve (AUROCs) <0.5 for the SOFT-score, P-SOFT-score, SALT-score and the labMELD-score ≥30 for the prediction of 3-month patient and graft survival as well as 1-year patient and graft survival. CONCLUSIONS Our results imply that the SOFT-score, P-SOFT-score, SALT-score and labMELD-score ≥30 all have a sensitivity, specificity and overall model correctness that is unable to discriminate short-term survivors from non-survivors in a collective of high-risk liver transplant recipients sufficiently in order to guide clinical decision making in the current German transplant situation with decreasing numbers of deceased liver donors, decreasing donor organ quality and increasingly sick transplant candidates.

The new liver allocation score for transplantation is validated and improved transplant survival benefit in Germany but not in the United Kingdom.

Prognostic models for the prediction of 90‐day mortality after transplantation with pretransplant donor and recipient variables are needed to calculate transplant benefit. Transplants in adult recipients in Germany (Hannover, n = 770; Kiel, n = 234) and the United Kingdom (Birmingham, n = 829) were used for prognostic model design and validation in separate training and validation cohorts. The survival benefit of transplantation was estimated by subtracting the observed posttransplant 90‐day mortality from the expected 90‐day mortality without transplantation determined by the Model for End‐Stage Liver Disease (MELD) score. A prognostic model called the liver allocation score (LivAS) was derived using a randomized sample from Hannover using pretransplant donor and recipient variables. This model could be validated in the German training and validation cohorts (area under the receiver operating characteristic curve [AUROC] > 0.70) but not in the English cohort (AUROC, 0.58). Although 90‐day mortality rates after transplantation were 13.7% in Hannover, 12.1% in Kiel, and 8.3% in Birmingham, the calculated 90‐day survival benefits of transplantation were 6.8% in Hannover, 7.8% in Kiel, and 2.8% in Birmingham. Deployment of the LivAS for limiting allocation to donor and recipient combinations with likely 90‐day survival as indicated by pretransplant LivAS values below the cutoff value would have increased the survival benefit to 12.9% in the German cohorts, whereas this would have decreased the benefit in England to 1.3%. The English and German cohorts revealed significant differences in 21 of 28 pretransplant variables. In conclusion, the LivAS could be validated in Germany and may improve German allocation policies leading to greater survival benefits, whereas validation failed in England due to profound differences in the selection criteria for liver transplantation. This study suggests the need for national prognostic models. Even though the German centers had higher rates of 90‐day mortality, estimated survival benefits were greater. Liver Transplantation 22 743–756 2016 AASLD.

Long-term outcome analysis of liver transplantation for severe hepatic trauma.

BACKGROUND Liver transplantation (LTX) for severe hepatic trauma and its sequelae is a rare but potentially lifesaving option at the far end of the operative spectrum. METHODS This study analyzes 12 cases with LTX for hepatic trauma and its consequences from two transplant centers. A total of 2,701 consecutive liver transplants unrelated to trauma served as a control group. &khgr;2 and Mann-Whitney U-tests, Kaplan-Meier analysis with log-rank tests, and Cox regression analysis were applied. Addressed were issues before, during, and after LTX. Major study end points were patient and graft survival. RESULTS The posttrauma transplant recipients are significantly younger (p = 0.014), with a significantly shorter graft survival (p = 0.038), resulting in a significantly higher retransplantation rate (p = 0.043). Of the 12 patients, 11 underwent surgical treatment for hepatic trauma before LTX with 7 of 12 patients experiencing liver necrosis at the time of LTX. Short-term survival and long-term survival are not significantly different between trauma and nontrauma patients. Severity of liver trauma (Moore Score) and concomitant injuries (Injury Severity Score [ISS]) have no significant impact on patient and graft survival. Four patients with hepatic trauma were treated with two-stage LTX with anhepatic phases between 14 hours and 28 hours. Two of those patients reached long-term survival (20–22 years). CONCLUSION LTX for severe liver trauma and its consequences seems justified in extreme cases. The high frequency of liver necrosis at the time of LTX may indicate possible shortcomings in liver packing technique or liver resection for hemorrhage control. Thus, severe hepatic trauma requires treatment by experienced liver surgeons and emergency physicians. LEVEL OF EVIDENCE Therapeutic study, level IV.

The new liver allocation score (LivAS) for transplantation is validated in germany improving transplant survival benefit but not in the UK

Prognostic models for the prediction of 90‐day mortality after transplantation with pretransplant donor and recipient variables are needed to calculate transplant benefit. Transplants in adult recipients in Germany (Hannover, n = 770; Kiel, n = 234) and the United Kingdom (Birmingham, n = 829) were used for prognostic model design and validation in separate training and validation cohorts. The survival benefit of transplantation was estimated by subtracting the observed posttransplant 90‐day mortality from the expected 90‐day mortality without transplantation determined by the Model for End‐Stage Liver Disease (MELD) score. A prognostic model called the liver allocation score (LivAS) was derived using a randomized sample from Hannover using pretransplant donor and recipient variables. This model could be validated in the German training and validation cohorts (area under the receiver operating characteristic curve [AUROC] > 0.70) but not in the English cohort (AUROC, 0.58). Although 90‐day mortality rates after transplantation were 13.7% in Hannover, 12.1% in Kiel, and 8.3% in Birmingham, the calculated 90‐day survival benefits of transplantation were 6.8% in Hannover, 7.8% in Kiel, and 2.8% in Birmingham. Deployment of the LivAS for limiting allocation to donor and recipient combinations with likely 90‐day survival as indicated by pretransplant LivAS values below the cutoff value would have increased the survival benefit to 12.9% in the German cohorts, whereas this would have decreased the benefit in England to 1.3%. The English and German cohorts revealed significant differences in 21 of 28 pretransplant variables. In conclusion, the LivAS could be validated in Germany and may improve German allocation policies leading to greater survival benefits, whereas validation failed in England due to profound differences in the selection criteria for liver transplantation. This study suggests the need for national prognostic models. Even though the German centers had higher rates of 90‐day mortality, estimated survival benefits were greater. Liver Transplantation 22 743–756 2016 AASLD.

Comparable outcome of liver transplantation with Histidine-Tryptophan-Ketoglutarate vs. University of Wisconsin preservation solution: a retrospective observational double-center trial

BackgroundThe question of whether the choice of preservation solution affects outcome after liver transplantation is still not satisfactorily answered. The purpose of this study is to examine the preservation solutions’ impact on outcome after liver transplantation.MethodsA double-center retrospective study of short- and long-term results of 3134 consecutive liver transplantations with follow-up periods up to 23 years was performed applying multivariate, risk-adjusted analyses with a subset for living-donor transplants, pediatric transplants and cases with prolonged cold ischemic times. An additional focus was put on biliary complications. The primary study endpoints were short- and long-term patient survival and death-censored graft survival. Secondary study endpoints were the occurrence of post-transplant complications, the necessity of operative revisions, the length of hospital stay, and the length of intensive care unit stay.ResultsAlthough long-term graft survival appears to be increased by Histidine-Tryptophan-Ketoglutarate-use (p = 0.018), this effect could not be confirmed in risk-adjusted analysis (p = 0.641). Multivariate regression analysis revealed that 3-month mortality (p = 0.120), 3-month graft survival (p = 0.103) and long-term patient survival (p = 0.235) were not influenced by the choice of preservation solution. There was no difference in the occurrence of common complications or necessity of operative revisions after liver transplantation. This was confirmed in subgroup analyses for living donor and pediatric transplantation and cases with prolonged cold ischemic time. Analysis of the preservation solutions’ impact on length of hospital (p = 0.113) and intensive care unit stay (p = 0.481) revealed no significant difference.ConclusionsUniversity of Wisconsin and Histidine-Tryptophan-Ketoglutarate solutions are clinically equivalent. Histidine-Tryptophan-Ketoglutarate solution could have an economically superior profile. The notion that the choice of preservation solution can have an impact on the onset of biliary complications after liver transplantation remains a matter of controversy.

The Glasgow prognostic score and its variants predict mortality in living donor but not in deceased donor liver transplantation for hepatocellular carcinoma: a double-center validation study†

This study aimed to evaluate whether the Glasgow Prognostic Score (GPS) and its variants are able to predict mortality in live donor and deceased donor liver transplantation for hepatocellular carcinoma.

[Does measuring axillo-rectal temperature difference help in the diagnosis of acute appendicitis?].

SummaryThe value of the axillorectal temperature difference in the diagnosis of acute appendicitis was estimated with the aid of statistical methods. The axillorectal temperature difference turned out to be of very low discriminant ability between acute appendicitis and non-acute conditions.ZusammenfassungDie Bedeutung der axillorectalen Temperaturdifferenz bei der Diagnostik der akuten Appendicitis wurde mit statistischer Methodik untersucht. Es zeigte sich, daß die axillorectale Temperaturdifferenz nur in sehr geringem Maß zwischen akuten und nicht akuten Befunden unterscheiden kann.The value of the axillorectal temperature difference in the diagnosis of acute appendicitis was estimated with the aid of statistical methods. The axillorectal temperature difference turned out to be of very low discriminant ability between acute appendicitis and non-acute conditions.