Nathalia M. Cardoso

A New Formula as a Predictive Score of Post–Liver Transplantation Outcome: Postoperative MELD-Lactate

INTRODUCTION Liver transplantation (OLT) involves a 5% to 10% 30-day mortality rate. Multiple scores have been used as predictors of early postoperative mortality, such as the original Model for End-stage Liver Disease (MELD) and MELD sodium. Investigations have been conducted over the last 5 years to find new predictors of early post-OLT mortality. OBJECTIVE The aim of this study was to develop a new mathematical model to predict the individual chance of 30-day mortality after OLT. METHODS The study was conducted on 58 patients submitted to OLT at the University Hospital, between October 2008 and March 2012. The 29 latest survivor and 29 latest nonsurvivor cases were selected. Arterial blood sodium, lactate, international normalized ratio, total bilirubin, and creatinine values were determined 1 hour after the end of surgery. The MELD original equation, MELD sodium, and new MELD lactate were also elaborated. The results were analyzed by the Mann-Whitney and Wilcoxon tests. The level of significance was set at .05. RESULTS The new formula elaborated was as follows: MELD lactate = 5.68 × loge (lactate) + 0.64 × (Original MELD) + 2.68. The MELD lactate values were significantly higher than the MELD sodium and original MELD values (P < .05). The area under the receiver operating characteristic curve of MELD lactate in predicting the outcome of patients submitted to OLT was 0.80, as opposed to 0.71 for the original MELD and 0.72 for MELD sodium (P < .05). CONCLUSION The postoperative MELD lactate score proved to be more specific and sensitive than the original MELD and MELD sodium as a predictive model of the outcome of patients submitted to OLT.

Can joint analysis of postoperative MELD, base excess and blood lactate levels be used as an index of postoperative outcome for patients submitted to liver transplantation?

PURPOSE The objective of the present study was to evaluate the postoperative levels of classical or pure MELD and changes in lactate or base excess (BE) levels as possible predictive factors of the type of outcome of patients submitted to orthotopic liver transplantation (OLT). METHODS The study was conducted on 60 patients submitted to OLT at the University Hospital, Faculty of Medicine of Ribeirão Preto, USP, between October 2008 and March 2012. The 30 latest survivor (S) and non-survivor (NS) cases were selected. All liver transplants were performed using the piggy-back technique. ALT, AST, BE and blood lactate values were determined for each group at five time points (immediate preoperative period, end of hypothermal ischemia, 5 and 60 minutes after arterial revascularization and in the immediate postoperative period, when the postoperative MELD was also calculated. RESULTS The aminotransferases reached a maximum increase 24 hours after surgery in both the S and NS groups. There was a significantly higher increase in BE and blood lactate in the NS group, especially after 5 minutes of afterial reperfusion of the graft, p<0.05. There was no significant difference in preoperative MELD between groups (p>0.05), while the postoperative MELD was higher in the NS than in the S group (p<0.05) CONCLUSION Joint analysis of postoperative MELD, BE and blood lactate can be used as an index of severity of the postoperative course of patients submitted to liver transplantation.

Considerations about a thematic Supplement containing papers related to translational research

The common understanding is that medical research in a department or in an area of clinical or surgical activity should be conducted in an eminently applied manner, without involving aspects of pure inquiry. In contrast to basic research, which is practically restricted to the understanding of the pathological, physiological or biomolecular processes of disease, experimental clinical research is of a practical, or even pragmatic nature. However, with the advances in knowledge and with the need for multidisciplinary and team work, modern investigation acquires a unique characteristic, i.e., it is performed in such a way that inquiry and application will occur in a synergistic translational manner. The term ‘translational research’ first appeared in PubMed in 1993, sparked by the characterization of BRCA1 and other cancer genes, which suggested immediate applications in early detection and treatment of cancer. Use of the term remained low throughout the 1990s, in just a handful of papers annually, until around 2000, after which it has cropped up in several hundred articles each year 1 . In 2000, the US Institute of Medicine convened the Clinical Research Roundtable, which held a series of meetings that are credited with placing translational research high on the agenda. The process pinpointed two blockages in the transfer of research knowledge into practice. The first roadblock (T1) was described by the roundtable as “the transfer of new understandings of disease mechanisms gained in the laboratory into the development of new methods for diagnosis, therapy, and prevention and their first testing in humans.” The roundtable described the second roadblock (T2) as “the translation of results from clinical studies into everyday clinical practice and health decision making.” 2 . In a comment published in 2008, Steven Woolf 2 stated

T-tube or no T-tube for bile duct anastomosis in orthotopic liver transplantation

Liver transplant is the established treatment for end-stage liver disease with standardized technique and reports of excellent results (1). Elective liver transplant in low risk patients have a 1-year survival rate of more than 90% (2). Improved outcomes are a result of careful patient selection, meticulous surgical techniques and attentive postoperative care. Increased survival has led to an escalation in the number of liver transplants being performed with over 15,000 patients being transplanted in the USA, Europe and China in 2010 (2). However, 10 to 30% of patients, submitted to whole organ liver transplantation, develop biliary complications with subsequent mortality of up to 10% (3,4). Approaches to reduce the incidence of biliary complications have included different techniques for anastomosis (for example side-to-side) and the use of T-tubes for duct-to-duct anastomosis.

Tu1027 A New Formula As a Predictive Score of Post-Liver Transplantation Outcome: Postoperative MELD Lactate

Introduction. Liver transplantation (OLT) involves a 5% to 10% 30-day mortality rate. Multiple scores have been used as predictors of early postoperative mortality, such as the original Model for End-stage Liver Disease (MELD) and MELD sodium. Investigations have been conducted over the last 5 years to find new predictors of early post-OLT mortality. Objective. The aim of this study was to develop a new mathematical model to predict the individual chance of 30-day mortality after OLT. Methods. The study was conducted on 58 patients submitted to OLT at the University Hospital, between October 2008 and March 2012. The 29 latest survivor and 29 latest nonsurvivor cases were selected. Arterial blood sodium, lactate, international normalized ratio, total bilirubin, and creatinine values were determined 1 hour after the end of surgery. The MELD original equation, MELD sodium, and new MELD lactate were also elaborated. The results were analyzed by the Mann-Whitney and Wilcoxon tests. The level of significance was set at .05. Results. The new formula elaborated was as follows: MELD lactate ¼ 5.68 � loge (lactate) þ 0.64 � (Original MELD) þ 2.68. The MELD lactate values were significantly higher than the MELD sodium and original MELD values (P < .05). The area under the receiver operating characteristic curve of MELD lactate in predicting the outcome of patients submitted to OLT was 0.80, as opposed to 0.71 for the original MELD and 0.72 for MELD sodium (P < .05). Conclusion. The postoperative MELD lactate score proved to be more specific and sensitive than the original MELD and MELD sodium as a predictive model of the outcome of patients submitted to OLT.

Prospective analysis of 44 consecutive liver transplants performed at a university hospital

PURPOSE To analyze the intraoperative and immediate postoperative biochemical parameters of patients submitted to orthotopic liver transplantation. METHODS Forty four consecutive orthotopic liver transplants performed from October 2009 to December 2010 were analyzed. The patients (38 male and eight female) were divided into two groups: group A, survivors, and group B, non-survivors. Fifty percent of group A patients were Chid-Pugh C, 40% Chid-Pugh B and 10% Chid-Pugh A. In group B, 52% of the patients were Chid-Pugh C, 41% Chid-Pugh B, and 17% Chid-Pugh A. All orthotopic liver transplants were performed by the piggy-back technique without a portacaval shunt in an anhepatic phase. ALT, AST, LDH and lactate levels were determined preoperatively, at five, 60 minutes after arterial revascularization of the graft and 24 and 48 hours after the end of the surgery.( or: after the surgery was finished). RESULTS There were no preoperative clinical differences (Child and Meld) between the two groups. The times of warm and hypothermal ischemia were similar for both groups (p>0.05). Serum aminotransferases levels at five and 60 minutes after arterial revascularization of the graft were similar (p>0.05) for both groups, as also were lactate levels at the time points studied. There was no significant difference in Δ lactate between groups at any time point studied (p>0.05). No significant difference was observed between groups during the first 24 and 48 hours after surgery (p>0.05). CONCLUSION No significant difference in any of the parameters studied was observed between groups. Under the conditions of the present study and considering the parameters evaluated, no direct relationship was detected between the intraoperative situation and the type of evolution of the patients of the two groups studied.