Change in model for end-stage liver disease score on the transplant waiting list predicts survival in patients undergoing liver transplantation

Allocation of donor livers through the model for end-stage liver disease (MELD) score has resulted in a fall in waiting list deaths in the United States. Change in MELD score (DeltaMELD) whilst awaiting transplant has been suggested as a method of refining organ allocation. Our aims were to analyse the effect of DeltaMELD between listing and transplant, and examine its impact on patient survival, intensive care stay and hospital stay in 402 patients transplanted for chronic liver disease at a single centre. Patients who had a DeltaMELD score of >+1 point were more likely to die in hospital following transplant (P < 0.05) and had a significantly worse 12- and 36-month survival post transplant (P < 0.0001) when compared with patients with DeltaMELD 相似文献   

肝移植治疗终末期自身免疫性肝病的预后分析

目的  探讨肝移植治疗终末期自身免疫性肝病(AILD)的预后情况。方法  回顾性分析1996年5月至2013年4月在第二军医大学附属长征医院实施原位肝移植术的48例终末期AILD受者的临床资料。计算受者的术后累积生存率,分析死亡病例的死因,了解术后排斥反应、病毒性肝炎新发感染及AILD复发情况。结果  48例AILD受者中,存活38例,AILD受者术后5年累积生存率为76%。10例死亡受者的死亡原因包括多器官功能衰竭、移植肝衰竭、脓毒症、肺部感染、出血、肝动脉栓塞、肾衰竭。48例AILD受者中,肝移植术后发生急性排斥反应者9例(19%),有3例分别在术后1~2年内新发乙型肝炎病毒感染,有2例原发性胆汁性肝硬化受者于术后2年出现原发病复发,经积极治疗均长期生存。结论  终末期AILD肝移植受者多数可获得长期生存,应重视肝移植术后早期免疫抑制方案的制定,预防感染及排斥反应和术后新发病毒性肝炎,及时发现原发病复发等问题。     

Impact of the model for end-stage liver disease score on mortality after liver transplantation

Objective

The objective of this study was to analyze survival, and mortality, rates as well as its causes during the month following liver transplantation with respect to the model for end-stage liver disease (MELD) model.

Material and Methods

We reviewed the mortality at 24 and 48 hours as well as 1 and 4 weeks of 380 transplanted patients over the past 7 years with regard to the MELD score.

Results

The mean patient age was 55 years. Among subjects with MELD score ≤ 15 (n = 142; 37.36%), there were 34 deaths (23.94%), including 7 (4.92%) who died during the first month. The mean cause of death during this period was hemorrhage (n = 3; 8.8%). Among those with MELD scores between 16 and 18 (n = 76; 20%), the mortality rate increased to 23.68% (n = 18), including 3 who died during the first month (3.94%) with 1 case due to hemorrhage. Among the cohort with MELD scores between 19 and 21 (n = 78; 20.52%), 25 (32.05%) died, including 9 during the first month (11.53%). The most frequent cause of death was septic shock (n = 5; 20%). The mortality rate among patients with a MELD score between 22 and 24 was 22% (n = 11), of which 8% (n = 4) died in the month. The mean cause of death during this period was multiple organ dysfunction (n = 2; 18.1%). The patient group with a MELD score >24 had a 32.3% mortality rate (n = 11); 4 patients died during the first month following transplantation (11.76%). The most frequent cause of death was hemorrhage (n = 2; 18.1%).

Conclusions

Survival during the first month did not seem to be related to the MELD score at the time of transplantation, nor did we observe a direct correlation between the MELD score and the overall risk of mortality.     

Pharmacokinetics and pharmacodynamics of cisatracurium in patients with end-stage liver disease undergoing liver transplantation

We determined the pharmacokinetics and pharmacodynamics of cisatracurium, one of the 10 isomers of atracurium, in 14 patients with end-stage liver disease undergoing liver transplantation and in 11 control patients with normal hepatic and renal function undergoing elective surgery. Blood samples were collected for 8 h after i.v. bolus administration of cisatracurium 0.1 mg kg-1 (2 x ED95). Plasma concentrations of cisatracurium and its metabolites were determined using an HPLC method with fluorescence detection. Pharmacokinetic variables were determined using non-compartmental methods. Neuromuscular block was assessed by measuring the electromyographic evoked response of the adductor pollicis muscle to train-of-four stimulation of the ulnar nerve using a Puritan-Bennett Datex (Helsinki, Finland) monitor. Pharmacodynamic modelling was completed using semi- parametric effect-compartment analysis. Volume of distribution at steady state was 195 (SD 38) ml kg-1 in liver transplant patients and 161 (23) ml kg-1 in control patients (P < 0.05), plasma clearance was 6.6 (1.1) ml kg-1 min-1 in liver transplant patients and 5.7 (0.8) ml kg-1 min-1 in control patients (P < 0.05), but elimination half-lives were similar: 24.4 (2.9) min in liver transplant patients vs 23.5 (3.5) min in control patients (ns). The time to maximum block was 2.4 (0.8) min in liver transplant patients compared with 3.3 (1.0) min in control patients (P < 0.05), but the clinical effective duration of action (time to 25% recovery) was similar: 53.5 (11.9) min in liver transplant patients compared with 46.9 (6.9) min in control patients (ns). The recovery index (25-75% recovery) was also similar in both groups: 15.4 (4.2) min in liver transplant patients and 12.8 (1.9) min in control patients (ns). After cisatracurium, peak laudanosine concentrations were 16 (5) and 21 (5) ng ml-1 in liver transplant and control patients, respectively. In summary, minor differences in the pharmacokinetics and pharmacodynamics of cisatracurium in liver transplant and control patients were not associated with any clinically significant differences in recovery profiles after a single dose of cisatracurium.      

Determination of the optimal model for end-stage liver disease score in patients with small hepatocellular carcinoma undergoing loco-regional therapy.

The model for end-stage liver disease (MELD) has been a prevailing system to prioritize cirrhotic patients awaiting liver transplantation. An "exceptional" MELD score of 20 and 24 points is assigned for stage T1 and T2 patients with small hepatocellular carcinoma (HCC), respectively. However, this strategy is based on scarce data and the optimal score for these patients remains uncertain. We investigated 238 patients with small HCC who were candidates for liver transplantation and underwent arterial chemoembolization or percutaneous injection therapy using acetic acid or ethanol. Tumor stage (P = .001) and Child-Turcotte-Pugh (CTP) class (P < .001) were independent risk factors predicting tumor progression or death in survival analysis. The risk of disease progression in HCC patients stratified by tumor stage was mapped and equated with the risk of mortality of 456 cirrhotic patients without HCC. The 6- and 12-month rates of disease progression were 4% and 6%, respectively, for stage T1 HCC patients (n = 50; mean MELD: 9.5). These rates were close to and no higher than the mortality rate in MELD category 8-12 at the corresponding time period (7.1% and 11.3%, respectively; n = 141). For stage T2 patients (n = 188; mean MELD: 9.3), the corresponding rates were 5.3% and 13.8%, respectively, which were close to and no higher than the mortality rate in MELD category 10-14 (9.0% and 13.9%, respectively, n = 166). In conclusion, the risk of disease progression is quite low for selected HCC patients undergoing loco-regional therapy. A lower MELD score may be suggested to be equivalent to the risk of short- and mid-term mortality in the cirrhosis group.     

The results of reduced-size liver transplantation, including split livers, in patients with end-stage liver disease.

We initiated a policy of using RSLT in critically ill patients in June of 1988. Since that time we have performed 30 RSLTs in 29 patients, including 28 children and 1 adult. The mean age of the children was 27 months (range 1 month to 10 years) with 14 (52%) being 1 year of age or less. The mean weight was 11.3 kg (range 2-50 kg) with 20 being 10 kg or less. A total of 22 patients were in the intensive care unit at the time of RSLT including 9 who were intubated. Of the 30 RSLTs, 23 were performed as a primary transplant while 7 were retransplants. Indications for primary transplantation included biliary atresia (n = 11), fulminant hepatic failure (n = 5), neonatal hepatitis (n = 4) and others (n = 3). The RSLT was used in retransplantation for primary nonfunction (n = 2), hepatic artery thrombosis (n = 2), chronic rejection (n = 2), and herpetic hepatitis (n = 1). The size reductions included 18 left lobes, 7 left lateral segments, and 5 right lobes. This group includes the use of the split-liver technique, which was applied to 10 patients (5 livers). The median donor/recipient weight ratio for left lobe transplants was 2:1; left lateral segments was 7.3:1; and right lobes 1.6:1. One year actuarial patient and graft survivals were 68 and 65%, respectively, with a mean follow-up of 10.6 months. The number of children dying awaiting transplantation has been significantly reduced following the introduction of RSLD (3 of 115, 2.6% vs. 12 of 95, 13%; P less than 0.02).     

终末期肝病模型评分较高的良性终末期肝病患者肝移植疗效评价

目的 探讨终末期肝病模型(MELD)评分较高的良性终末期肝病患者的肝移植疗效.方法 回顾分析80例良性终末期肝病肝移植患者的资料,根据MELD评分的不同将患者分成两组,MELD评分≥30分的23例为高MELD评分组,MELD评分＜30分的57例为低MELD评分组.分别比较两组患者手术时间、术中无肝期、术中血液制品输入量、术后重症监护病房(ICU)治疗时间和受者1年存活率,同时比较死亡患者和存活患者的临床资料,寻找导致术后死亡的危险因素.结果 高MELD评分组的手术时间、术中血液制品输入量、ICU治疗时间以及术后3个月内的死亡率明显高于低MELD评分组,差异有统计学意义(P＜0.05),而术中无肝期和患者1年存活率,两组间的差异无统计学意义(P＞0.05).死亡者和存活者相比较,MELD评分的差异无统计学意义(P＞0.05),而术前机械通气、血清钠水平、持续性肝性脑病(重型)等方面的差异有统计学意义(P＜0.05).结论 对于良性终末期肝病患者,单纯依靠MELD评分不足以准确判断患者肝移植术后的生存状态,高MELD评分者也可获得较好的肝移植结果,术前严重的低钠血症、重度肝性脑病以及机械通气是除MELD评分以外影响患者术后生存状况的危险因素.     

Emergent right lobe adult-to-adult living-donor liver transplantation for high model for end-stage liver disease score severe hepatitis

The aim of this study was to explore the feasibility of emergency right lobe adult-to-adult living-donor liver transplantation (LDLT) for high model for end-stage liver disease (MELD) score severe hepatitis. Consecutive 10 high MELD score severe hepatitis patients underwent emergency right lobe adult-to-adult LDLT in our hospital from April to December 2007. The MELD score was 34.50 ± 2.088. The outcomes of these recipients were retrospectively analyzed. Among them, eight cases of ABO blood group were identical and two cases compatible, one case was Rh negative. Two recipients died and the rest of the recipients and all donors are safe; perioperative and 2-year survival rate was 80%. The mean graft-recipient weight ratio (GRWR) was 1.27% ± 0.25%, and graft volume to recipient standard liver volume ratio (GV/ESLVR) was 56.7% ± 6.75%. Of the 10 patients, three received right lobe grafts with middle hepatic vein (MHV), four without MHV, three without MHV but followed by V and VIII hepatic vein outflow reconstruction. An encouraging outcome was achieved in this group: elevated serum creatinine, serum endotoxin, decreased serum prothrombin activity, and Tbil returned to normal on postoperative days 3, 7, 14, and 28, respectively. One-year survival rate was 80%. Outcomes of emergency right lobe adult-to-adult LDLT for high MELD score severe hepatitis were fairly encouraging and acceptable. Emergency right lobe adult-to-adult LDLT is an effective and life-saving modality for high MELD score acute liver failure patients following severe hepatitis.     

高MELD评分终末期肝病患者接受中国公民逝世后器官捐献供肝肝移植的近期疗效评价

目的  探讨高终末期肝病模型(MELD)评分终末期肝病患者接受中国公民逝世后器官捐献供肝肝移植的近期疗效和安全性。 方法  回顾性分析2011年9月至2014年6月在佛山市第一人民医院实施公民逝世后器官捐献供肝肝移植并存活的34例受者的临床资料。根据术前MELD评分, 将受者分为高MELD组(MELD评分≥25分, 8例)和低MELD组(MELD评分 < 25分, 26例)。比较两组受者肝移植术前、术中和术后情况。 结果  术前, 高MELD组需要人工肝治疗者比例、急性肝衰竭和慢加急性肝衰竭的发生率均高于低MELD组(均为P < 0.05)。术中, 两组受者的出血量、输血量、供肝热缺血时间、供肝冷缺血时间、无肝期、手术时间、手术方式等比较, 差异均无统计学意义(均为P > 0.05)。术后, 高MELD组的入住ICU时间长于低MELD组(P < 0.05)。两组术后住院时间、住院病死率、早期并发症发生率、随访时间、总体生存率方面比较, 差异无统计学意义(均为P > 0.05)。肝移植术后高MELD组的天冬氨酸转氨酶(AST)峰值高于低MELD组。两组受者术后胆漏、腹腔脓肿和肝功能不全的发生率比较, 差异有统计学意义(均为P < 0.05)。 结论  高MELD评分终末期肝病患者接受中国公民逝世后器官捐献供肝肝移植能取得较好的近期效果且安全可行。     

High model for end-stage liver disease score as a predictor of survival during long-term follow-up after liver transplantation

Background

The allocation of cadaveric livers for transplantation in the United States is now based on the severity of illness as determined by the Model for End-Stage Liver Disease (MELD), which was developed to predict short-term mortality in patients with cirrhosis. However, its impact to predict posttransplantation survival is controversial. The objective of this study was to determine the association of various pretransplantation risk factors, including the MELD score and whether its use to allocate organs is likely to lead to overall poorer outcomes of liver transplantation.

Methods

The 1,032 consecutive adult liver transplantation patients at King's College Hospital between 2 January 1994 and 29 December 2001 were examined for 9 preoperative risk factors, including MELD score, using univariate and multivariate techniques. Based on their pretransplantation MELD scores, we categorized recipients as low (<15) medium (15-25), or high (>25). Kaplan-Meier patient survival analysis was used to identify differences in outcomes.

Results

The patients had a mean age of 47.2 years and mean posttransplantation follow-up of 5.3 years. Univariate analysis showed recipient diabetes mellitus, renal dysfunction, and pretransplantation MELD score to be associated with patient survival. Multivariate analysis showed the MELD score to be significantly associated with death during long-term follow-up.

Conclusions

A high pretransplantation MELD score was associated with poor posttransplantation outcomes.     

Adult-to-adult right-lobe living donor liver transplantation in high model for end-stage liver disease score recipients with hepatitis B virus-related benign liver diseases

Purpose

We evaluated the safety and efficacy of adult-to-adult right-lobe living donor liver transplantation (ARL-LDLT) in HBV-related benign liver disease recipients with high model for end-stage liver disease (MELD) scores.

Methods

The subjects of this study were 70 adult patients who underwent ARL-LDLT and 191 who underwent DDLT, for HBV-related end-stage liver diseases, between May 2002 and December 2009. Short-term outcomes were assessed by 30-day mortality and graft loss, parameters indicating graft dysfunction, length of hospital stay, and postoperative complications within 3 months. Long-term transplant outcomes were measured by graft- and patient survival and HBV recurrence rates at 1, 3, and 5 years.

Results

There were no differences in donor outcomes or recipient short-term outcomes between the groups, although recipients with a high MELD score (Group H) had a higher incidence of pneumonia. High MELD score versus low MELD score recipients had similar 1-, 3-, and 5-year patient survival rates and post-transplant HBV recurrence rates. In the matched DDLT cases, a similar tendency was observed between group H and group L.

Conclusions

ARL-LDLT can be performed safely and effectively in high-MELD score patients with HBV-related benign liver disease; thus, a high MELD score may not contraindicate ARL-LDLT.     

Assignment of steatotic livers by the Mayo model for end-stage liver disease

Prognosis after liver transplantation depends on a combination of recipient and donor variables. The purpose of this study is to define an allocation system of steatotic donor livers relative to recipient model for end-stage liver disease (MELD) score. We reviewed 500 consecutive OLT, computing the MELD score for each recipient. Fatty infiltration in grafts was categorized in no steatosis, 10-30%, 30-60% and > or = 60% steatosis. MELD score did not affect preservation injury and graft dysfunction, which were increased with fat content. Recipient and graft survivals lowered when increasing MELD score. Outcome in low-risk recipients (MELD < or = 9) was not altered with steatosis, except those with > or = 60%. Survival functions in moderate-risk recipients (MELD 10-19) were moderately affected with 10-30% steatosis and severely with those with >30. Exactly 30-60% steatotic grafts work poorly in high-risk recipients (MELD > or = 20), and very poorly with > or = 60% steatosis. Prognosis of candidates is optimally influenced when divergence of recipient-donor risks is presented.     

Calculation and comparison of the model for end-stage liver disease (MELD) score in patients accepted for liver transplantation in 1999 and 2004

There has been a need to assess the "sickness degree" in patients with acute and chronic hepatic failure. The Model for End-Stage Liver Disease (MELD) score was developed as a tool for a more objective estimate of the "degree" of sickness in patients with chronic liver disease. In this study, the MELD score was retrospectively calculated and compared in adult patients accepted for orthotopic liver transplantation (OLT) in our institution in 1999 and 2004. We analyzed the gender, age, and MELD score associated with different indications for OLT during this period.     

Model for end-stage liver disease score versus simplified acute physiology score criteria in acute renal failure after liver transplantation

Hepatic function and renal failure are closely related among patients with end-stage liver disease (ESLD) due to splanchnic hemodynamic mechanisms that characterize advanced decompensated cirrhosis. Acute renal failure (ARF) is a frequent complication that occurs immediately post-orthotopic liver transplantation (OLT). The Model for End-stage Liver Disease (MELD) score describes the survival of patients with ESLD awaiting OLT related to the severity of liver disease. The Simplified Acute Physiology Score (SAPS II) is a mortality prediction model that scores the severity of illness among intensive care unit patients. In a previous study we observed an association between ARF post-OLT and a higher MELD score, but it was not clear whether this association depends on the grade of ESLD or on the critical condition of liver transplant patients. The aim of this study was to evaluate the association of ARF with MELD score and/or SAPS II criteria among liver transplant patients. We analyzed 46 patients with ESLD who underwent deceased donor OLT. All patients were evaluated at baseline and in the first 7 days post-OLT. According to the RIFLE classification, the incidence of the worst grade of ARF post-OLT was 19.2%. These patients showed significantly higher MELD scores, while there was no association with systemic parameters related to the critical patient's condition or with the mortality score as evaluated by SAPS II criteria. We confirmed the association between renal failure and hepatic function among liver transplant patients. A more severe degree of hepatic dysfunction before OLT was associated with a greater incidence of ARF that can adversely affect patient survival.     

A high model for end-stage liver disease score should not be considered a contraindication to living donor liver transplantation

Objective

To analyze the outcomes of patients with high Model for End-Stage Liver Disease (MELD) scores who underwent adult-to-adult live donor liver transplantation (A-A LDLT).

Materials and Methods

From September 2002 to October 2010, a total of 152 adult patients underwent A-A LDLT in our institution. Recipients were stratified into a low MELD score group (Group L; MELD score ≤30) and a high MELD score group (Group H; MELD score >30) to compare short-term and long-term outcomes.

Results

Of the 152 adult patients who underwent A-A LDLT, 9 were excluded from the analysis because they received ABO-incompatible grafts. Group H comprised 23 and Group L 120 patients. The median follow-up was 21.5 months (range, 3 to 102 m). The mean MELD score was 15.6 in Group L and 36.7 in Group H. There were no significant differences in the mean length of stay in the intensive care unit (Group L: 3.01 days vs Group H: 3.09 days, P = .932) or mean length of hospital stay (Group L: 17.89 days vs. Group H: 19.91 days, P = 0.409). There were no significant differences in 1-, 3-, or 5-year survivals between patients in Groups L versus H (91.5% vs 94.7%; 86.4% vs 94.7%; and 86.4% vs 94.7%; P = .3476, log rank).

Conclusion

The short-term and long-term outcomes of patients with high MELD scores who underwent A-A LDLT were similar to those of patients with low MELD scores. Therefore, we suggest that high MELD scores are not a contraindication to LDLT.     

Prognostic factors in patients with acute liver failure undergoing live donor liver transplantation

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.     

门静脉血栓对终末期肝硬化病人行肝移植手术的影响

目的探讨合并门静脉血栓(portal vein thrombosis,PVT)的终末期肝硬化病人行肝移植手术的处理方法及其疗效。方法回顾性分析2010年1月至2015年12月在中山大学附属第一医院器官移植中心接受肝移植手术的152例终末期肝硬化病人的临床资料。32例合并PVT的病人作为PVT组,其中Ⅰ级10例、Ⅱ级13例、Ⅲ级8例、Ⅳ级1例。其余120例无PVT的病人作为对照组。结果PV/T组术前脾切除史的比例明显高于对照组(46.8%比18.3%,P0.05),差异有统计学意义。PVT组较对照组明显延长无肝期时间[(72.5±25.3)min比(57.6±18.4)min,P0.05]和总手术时间[(622.4±183.5)min比(503.2±123.6)min],差异均有统计学意义。2组病人在术中出血量、ICU住院时间、术后并发症发生率、围手术期病死率、1年及3年生存率的比较上差异均无统计学意义(P0.05)。PVT组术后再栓塞率高于对照组(9.4%比1.7%,P0.05)。结论门静脉血栓一定程度上增加了终末期肝硬化病人肝移植手术的难度,Ⅰ~Ⅲ级PVT不影响病人的预后,仍可通过肝移植手术取得良好的疗效。Ⅳ级PVT肝移植手术的难度和风险会明显增加,应谨慎对待。