Kelly M. Collins

Morbid obesity in liver transplant recipients adversely affects longterm graft and patient survival in a single-institution analysis

OBJECTIVE The effects of obesity in liver transplantation remain controversial. Earlier institutional data demonstrated no significant difference in postoperative complications or 1-year mortality. This study was conducted to test the hypothesis that obesity alone has minimal effect on longterm graft and overall survival. METHODS A retrospective, single-institution analysis of outcomes in patients submitted to primary adult orthotopic liver transplantation was conducted using data for the period from 1 January 2002 to 31 December 2012. Recipients were divided into six groups by pre-transplant body mass index (BMI), comprising those with BMIs of <18.0 kg/m(2) , 18.0-24.9 kg/m(2) , 25.0-29.9 kg/m(2) , 30.0-35.0 kg/m(2) , 35.1-40.0 kg/m(2) and >40 kg/m(2) , respectively. Pre- and post-transplant parameters were compared. A P-value of <0.05 was considered to indicate statistical significance. Independent predictors of patient and graft survival were determined using multivariate analysis. RESULTS A total of 785 patients met the study inclusion criteria. A BMI of >35 kg/m(2) was associated with non-alcoholic steatohepatitis (NASH) cirrhosis (P < 0.0001), higher Model for End-stage Liver Disease (MELD) score, and longer wait times for transplant (P = 0.002). There were no differences in operative time, intensive care unit or hospital length of stay, or perioperative complications. Graft and patient survival at intervals up to 3 years were similar between groups. Compared with non-obese recipients, recipients with a BMI of >40 kg/m(2) showed significantly reduced 5-year graft (49.0% versus 75.8%; P < 0.02) and patient (51.3% versus 78.8%; P < 0.01) survival. CONCLUSIONS Obesity increasingly impacts outcomes in liver transplantation. Although the present data are limited by the fact that they were sourced from a single institution, they suggest that morbid obesity adversely affects longterm outcomes despite providing similar short-term results. Further analysis is indicated to identify risk factors for poor outcomes in morbidly obese patients.

Outcomes Using Grafts from Donors after Cardiac Death

BACKGROUND Previous reports suggest that donation after cardiac death (DCD) liver grafts have increased primary nonfunction (PNF) and cholangiopathy thought to be due to the graft warm ischemia before cold flushing. STUDY DESIGN In this single-center, retrospective study, 866 adult liver transplantations were performed at our institution from January 2005 to August 2014. Forty-nine (5.7%) patients received DCD donor grafts. The 49 DCD graft recipients were compared with all recipients of donation after brain death donor (DBD) grafts and to a donor and recipient age- and size-matched cohort. RESULTS The DCD donors were younger (age 28, range 8 to 60 years) than non-DCD (age 44.3, range 9 to 80 years) (p < 0.0001), with similar recipient age. The mean laboratory Model for End-Stage Liver Disease (MELD) was lower in DCD recipients (18.7 vs 22.2, p = 0.03). Mean cold and warm ischemia times were similar. Median ICU and hospital stay were 2 days and 7.5 days in both groups (p = 0.37). Median follow-ups were 4.0 and 3.4 years, respectively. Long-term outcomes were similar between groups, with similar 1-, 3- and 5-year patient and graft survivals (p = 0.59). Four (8.5%) recipients developed ischemic cholangiopathy (IC) at 2, 3, 6, and 8 months. Primary nonfunction and hepatic artery thrombosis did not occur in any patient in the DCD group. Acute kidney injury was more common with DCD grafts (16.3% of DCD recipients required dialysis vs 4.1% of DBD recipients, p = 0.01). An increased donor age (>40 years) was shown to increase the risk of IC (p = 0.006). CONCLUSIONS Careful selection of DCD donors can provide suitable donors, with results of liver transplantation comparable to those with standard brain dead donors.

Donor Age-Based Analysis of Liver Transplantation Outcomes: Short- and Long-Term Outcomes Are Similar Regardless of Donor Age

BACKGROUND The shortage of donor organs has led to increasing use of extended criteria donors, including older donors. The upper limit of donor age that produces acceptable outcomes continues to be explored. In liver transplantation, with appropriate selection, graft survival and patient outcomes would be comparable regardless of age. STUDY DESIGN We performed a retrospective analysis of 1,036 adult orthotopic liver transplantations (OLT) from a prospectively maintained database performed between January 1, 2000 and December 31, 2013. The study focus group was liver transplantations performed using grafts from older (older than 60 years) deceased donors. Deceased donor liver transplantations done during the same time period using grafts from younger donors (younger than 60 years) were analyzed for comparison. Both groups were further divided based on recipient age (less than 60 years and 60 years or older). Donor age was the primary variable. Recipient variables included were demographics, indication for transplantation, Model for End-Stage Liver Disease (MELD), graft survival, and patient survival. Operative details and postoperative complications were analyzed. RESULTS Patient demographics and perioperative details were similar between groups. Patient and graft survival rates were similar in the 4 groups. Rates of rejection (p = 0.07), bile leak (p = 0.17), and hepatic artery thrombosis were comparable across all groups (p = 0.84). Hepatitis C virus recurrence was similar across all groups (p = 0.10). Thirty-one young recipients (less than 60 years) received grafts from donors aged 70 or older. Their survival and other complication rates were comparable to those in the young donor to young recipient group. CONCLUSIONS Comparable outcomes in graft and patient survivals were achieved using older donors (60 years or more), regardless of recipient age, without increased rate of complications.

Clinician perceptions of operating room to intensive care unit handoffs and implications for patient safety: a qualitative study

BACKGROUND Operating room (OR) to the intensive care unit (ICU) handoffs are known sources of medical error, yet little is known about the relationship between process failures and patient harm. METHODS Interviews were conducted with clinicians involved in the OR-to-ICU handoff to characterize the relationship between handoff process failures and patient harm. Qualitative analysis was used to inductively identify key themes. RESULTS A total of 38 interviews were conducted. Dominant themes included early communication from the OR to the ICU, team member participation in the handoff, and relationships between clinicians; clinician perspectives varied depending substantially on role within the team. CONCLUSIONS The findings suggest that ambiguous roles and conflicting expectations of team members during the OR-to-ICU handoff can increase risk of patient harm. Future studies should investigate early postoperative ICU care as outcome markers of handoff quality and the effect of interprofessional education on clinician adherence to interventions.

Outcome of liver transplantation in patients with prior bariatric surgery

Nonalcoholic fatty liver disease is becoming the leading cause of disease resulting in liver transplantation (LT). As a result of this trend, more LT candidates are presenting with prior history of bariatric surgery (BS). Over the last decade, 960 patients underwent LT at our institution; 11 (1.1%) had prior BS. The most common type of BS was Roux‐en‐Y gastric bypass (n = 9) with 1 sleeve gastrectomy and 1 jejunoileal bypass. A total of 9 patients underwent LT alone, and 2 underwent simultaneous liver‐kidney transplantation. The most common indication for LT was nonalcoholic steatohepatitis (n = 10) with 5 having additional diagnosis of alcoholic liver disease. The 30‐day reoperation rate was 36.4% (n = 4); indications were bile duct repair (n = 3) and wound repair (n = 1). In the first 6 months after LT, biliary complications were seen in 54.5% (n = 6) of the patients. Both patient and graft survival rates at 1 and 2 years were 81.8% (n = 9) and 72.7% (n = 8), respectively. A total of 8 patients (72.7%) had indications for liver biopsy after LT; significant macrovesicular steatosis was found in 2 (18.2%). In patients with a history of alcohol consumption, 2 (40.0%) relapsed after LT. Two patients (18.2%) had a history of diet‐controlled diabetes before LT; 1 of these patients became insulin dependent after LT. Mean body mass index (BMI) at LT was 31.0 ± 5.7 kg/m2. Mean BMI at 1, 6, and 12 months after LT was 28.3 ± 5.8, 28.0 ± 3.2, and 31.0 ± 6.6 kg/m2, respectively. Mean preoperative albumin was 2.6 ± 0.6 mg/dL. Patients showed improvement in albumin after LT, with mean albumin of 2.7 ± 0.6 and 3.2 ± 0.5 mg/dL at 1 and 3 months, respectively. The liver profile was stable after LT, with mean aspartate aminotransferase of 32.9 ± 18.4 and 26.6 ± 19.8 IU/L and alanine aminotransferase of 28.0 ± 17.5 and 30.2 ± 17.0 IU/L at 6 and 12 months, respectively. In conclusion, outcomes of LT patients with prior BS are comparable with other transplant recipients with regards to patient and graft survival and post‐LT complication rates. Liver Transplantation 23 1415–1421 2017 AASLD.

High‐risk liver transplant candidates: An ethical proposal on where to draw the line

Schiano et al. use this case report to open a discussion of liver transplantation allocation ethics with an emphasis on the role of posttransplant recipient survival. They argue that the current system undervalues utility by virtue of its lack of consideration of posttransplant survival. The authors propose that a benchmark of an estimated posttransplant survival of 50% be established for eligibility for transplantation. Their argument must be placed in a framework that includes both the history and the ethical basis of organ allocation in the United States. Deceased organs are accepted as a scarce and precious resource. In 2013, 15,027 candidates were listed for a liver transplant; however, 1767 died while awaiting transplant, and 1223 were removed from the waiting list as a result of being too sick. This pervading presence of mortality faced by both the recipients and the donor families along with the gravity of the gift and the scarcity of the resource results in strong beliefs regarding allocation and creates fertile ground for moral discourse. The policies and procedures of organ procurement and allocation seek to balance legal rights and fundamental but not universally shared societal beliefs. The survival of organ transplantation is achieved only with community trust in the system of procurement and allocation and in those people entrusted with this responsibility. Because of the paramount importance of this covenant between community and providers, the National Organ Transplant Act of 1984 was implemented in an effort to create a transparent system that would ensure equity in the allocation of organs. The Organ Procurement and Transplantation Network was contracted to administer organ transplantation in the United States, with oversight from the government through the Department of Health and Human Services (DHHS). The United Network for Organ Sharing, a not-for-profit organization that is directed by a board consisting of medical professionals, transplant recipients, and donor family members, was contracted to aid with the development and administration of transplant policies. In 1999, the DHHS implemented the final rule, which mandated that the allocation policy needed to better prioritize medical urgency. The Model for End-Stage Liver Disease (MELD) score was adopted in response to this in an effort to increase objectivity and medical urgency in allocation. The result has been a de-emphasis on time on the waiting list and categorical status–based allocation, with priority now being based on medical urgency. Its employment has resulted in a significant decline in death on the wait list, without significant worsening of posttransplant survival. Since its inception, it has been acknowledged as an imperfect model, with its major weaknesses being its inability to predict posttransplant outcomes and its neglect of the morbidityand mortality-related sequelae of liver disease that develop in some, but not all, patients (ie, hepatocellular cancer and hepatopulmonary syndrome). Although the system of exception points has allowed the incorporation of these conditions, the national policy still lacks representation of posttransplant survival. The ethics of organ allocation is based on the balance of two major ethical principles: utility and justice. The utilitarian view of allocation argues that the system

Hazard Ratio Trends Among Deceased Liver Transplant Recipients in The United States, 2011-2016: A Propensity Score-Matched Study

Background Donation after cardiac death (DCD) donor liver graft is a known risk factor for graft failure secondary to primary non-function (PNF) and/or diffuse cholangiopathy (DC). We used propensity score-matching (PSM) to study mortality and graft failure hazard ratio trends among DCD vs. donation after brain death (DBD) recipients. Methods Retrospective data of adult recipients ≥18 years from the national United Network for Organ Sharing registry 2011-2016 were analyzed. Clinically significant donor, recipient, and operative characteristics were balanced among donor groups. All-cause mortality, all-cause graft failure, graft failure due to DC and PNF were estimated using Cox proportional hazards models. Results Among a total of 29573 recipients, 1800 (6.09%) received DCD livers. Overall, DCD recipients should expect worse 2-year all-cause mortality, 2-year all-cause graft failure, 2-year graft failure due to DC, and 1-year graft failure due to PNF in comparison to DBD recipients (HR=1.43, 1.45, 7.87, and 2.56, respectively). Figure 1 presents trends in the crude and PSM hazard ratios of DCD vs. DBD recipients. All-cause mortality for both crude and PSM adjusted estimates, as well as all-cause graft failure, indicate declining trends (P=0.015, <0.001, <0.001, and 0.002, respectively). Whereas crude hazard trends for DC and PNF are statistically becoming worse for DCD recipients (P=0.002 and <0.001, respectively). Among the most recent time period (2015-2016): the hazard for all-cause mortality was null, 39% increased hazard for all-cause graft failure, 569% increased hazard for DC, and 176% increased hazard for PNF among DCD in comparison to DBD. Conclusions All-cause PSM mortality and graft failure hazard declined from 2011 through 2016. Based on this trend future DCD and DBD recipients should expect identical two-year survival as well as near similar graft function. However, we are observing more PNF recently among DCD recipients. Future data is required to confirm whether DC and PNF outcomes are improving or worsening over time amongst deceased liver transplant recipients.

Liver Transplantation for Common Bile Duct Injury

Indications for liver transplantation after bile duct injury fall into two major categories: Chronic liver disease due to secondary biliary cirrhosis and acute liver failure due to an associated major vascular injury. The exact incidence of liver transplantation due to biliary injury is difficult to estimate because the etiology of liver failure for these patients is not always adequately captured in current transplant registries. There is a rare but important role and need for liver transplant in highly selected cases of bile duct injury. While the etiology of obstruction leading to secondary biliary cirrhosis is not consistently reported, most cases series describe the use of transplantation as a consequence of iatrogenic injury.