Identifying a targeted population at high risk for infections after liver transplantation in the MELD era

Sun H‐Y, Cacciarelli TV, Singh N. Identifying a targeted population at high risk for infections after liver transplantation in the MELD era.
Clin Transplant 2011: 25: 420–425. © 2010 John Wiley & Sons A/S. Abstract: Impact of model for end‐stage liver disease (MELD) scoring system on post‐transplant infections and associated risk factors are unknown. Infections <90 d post‐transplant were assessed in 277 consecutive liver transplant recipients from 1999 to 2008. “High‐risk” factors for infections were pre‐defined as MELD score >30, ICU stay >48 h prior to transplant, intraoperative transfusion ≥15 units, retransplantation, post‐transplant dialysis, or reoperation. Of the 240 recipients in the MELD era (2002–2008), 48.5% had any high‐risk factor. The OR for infection was 1.69, 2.00, 18.00, and 4.50 in recipients with any 1, 2, 3, and ≥4 high‐risk factors, respectively (χ² for trend, p < 0.001). In logistic regression model, recipient age (OR 1.12, p < 0.05) and any high‐risk factor (OR 2.42, p < 0.05) were associated with infections. Compared with 37 pre‐MELD recipients, the overall infections and mortality at 12 months did not differ in the two eras. In Cox regression model, recipient age (OR 1.09, p < 0.05) and any high‐risk factor (OR 2.42, p < 0.05) remained associated with infections. The overall frequency of infections did not increase in the MELD era. Pre‐defined risk factors accurately predicted the risk of infections in these patients.     

Dynamic changes in MELD score not only predict survival on the waiting list but also overall survival after liver transplantation

The predictive value of MELD score for post‐transplant survival has been under constant debate since its implementation in 2001. Aim of this study was to assess the impact of alterations in MELD score throughout waiting time (WT) on post‐transplant survival. A single‐centre retrospective analysis of 1125 consecutive patients listed for liver transplantation between 1997 and 2009 was performed. The impact of MELD score and dynamic changes in MELD score (DeltaMELD), as well as age, sex, year of listing and WT were evaluated on waiting list mortality and post‐transplant survival. In this cohort, 539 (60%) patients were transplanted, 223 (25%) died on list and 142 (15%) were removed from the waiting list during WT. One‐, three‐ and five‐year survival after liver transplantation were 83%, 78% and 76% respectively. DeltaMELD as a continuous variable proved to be the only significant risk factor for overall survival after liver transplantation (hazard ratio (HR): 1.06, 95% confidence interval (CI) 1.02–1.1, P = 0.013). The highest risk of post‐transplant death could be defined for patients with a DeltaMELD > 10 (HR: 4.87, 95% CI 2.09–11.35, P < 0.0001). In addition, DeltaMELD as well as MELD at listing showed a significant impact on waiting list mortality. DeltaMELD may provide an easy evaluation tool to identify patients on the liver transplant waiting list with a high mortality risk after transplantation in the current setting. Temporarily withholding and re‐evaluating these patients might improve overall outcome after liver transplantation.     

The introduction of MELD-based organ allocation impacts 3-month survival after liver transplantation by influencing pretransplant patient characteristics

Introduction of the model of end-stage liver disease (MELD) for organ allocation has changed the waiting-list management. Despite reports of unaffected survival after orthotopic liver transplantation (OLT) in the MELD era, survival rates have decreased in our center. The aim of this study was to identify factors contributing to reduced survival. Three-month survival, recipient and graft parameters of all 323 OLT between 2004 and 2008, which fall into a pre- ( N  = 220) and a post-MELD ( n  = 103) era, were analysed by Kaplan–Meier-, Mann–Whitney- and Fisher tests. After the introduction of MELD, mean scores at OLT increased (14.8 vs. 18.6, P  = 0.002). The main indications for OLT were not statistically different between eras. Post-MELD recipients were older (47.9 vs. 50.9 years, P  = 0.025), donors younger (NS), cold ischemia time shorter (696 vs. 635 min., P  = 0.001), and duration of surgery longer (218 vs. 245 min., P  = 0.001). Procedure time significantly correlated with MELD and international normalized ratio (INR). Three-month survival dropped (from 88.6% to 79.6%, P  = 0.03). Independent variables of survival were creatinine, urea and duration of surgery. Reduced 3-month survival was associated with longer surgery duration, higher creatinine and urea likely reflecting higher recipient morbidity. Survival probability should be incorporated into MELD-based graft allocation.     

MELD评分对肝移植手术患者预后的预测价值

目的探讨术前终末期肝病模型（model for end－stage liver disease,MELD）评分在肝移植治疗终末期肝病早期预后中的预测价值。方法回顾106例终末期肝病患者行肝移植治疗的临床资料,计算术前MELD评分,根据并发症、死亡检验ROC曲线中最佳曲线Youden指数最高时的MELD截断值进行分组,并对各组早期并发症发生率和生存率结果进行分析。结果本组106例肝移植患者中各种严重并发症发生率为29．25％,住院28d和术后3个月生存率分别为90．57％和89．62％;非并发症组、并发症组以及生存组、死亡组的MELD评分均值分别为12．00、21．19和13.28、28．27,其MELD分值差异有统计学意义（P〈0．01）：评价并发症的ROC曲线下面积为0．24±0．05（P〈0．01）,死亡检验ROC曲线下面积为0．87±0．06（P〈0．01）,死亡检验ROC曲线Youden指数最高时的MELD截断值分别为18.42和27．15;与MELD≤18．42组相比,18．42—27．15组和≥27．15组两组的并发症发生率、死亡率均显著增加（P〈0．01）。结论终末期肝病患者术前MELD评分分值越高,肝移植后早期严重并发症发生率和死亡率越高：MELD分值对行肝移植术的患者发生严重并发症的预测效果较差,但对死亡的预测效果较好：高分值MELD（≥27．15）是预测肝移植患者术后高并发症发生与死亡的较好指标。     

Predictors of death on the waiting list for liver transplantation characterized by a long waiting time

The number of patients dying while on the liver transplantation (LT) waiting list (WL) has continued to increase in recent years as a result of severe shortage of organs. Therefore, it is important to evaluate the existing models that predict death on the WL and to determine the independent predictors of death. The study cohort comprised 152 adult patients listed for LT in our centre over a period of 2 years (January 2001 to January 2003). The 12-month survival rate has been calculated by Kaplan-Meier method. The survival analysis performed by Cox proportional hazard model has evaluated the three parameters which compose the model for end-stage liver disease (MELD) score. Forty-four patients (28.9%) died while listed for LT. The survival rate was 92% at 3 months, 80% at 6 months and 69% at 12 months. Median survival was not reached. MELD score was found to be an excellent predictor of death at 12 months on our WL--c-statistic (area under curve) 0.84. In our survival analysis, only international normalized (prothrombin) ratio (INR) and serum creatinine were identified as an independent predictors of death (P < 0.0001). A new simplified version of the MELD score, which does not include serum bilirubin, is proposed and its c-statistic as predictor for death on the WL at 12 months is 0.86, as good as the original MELD score, when evaluated on our list. There is a fourfold increase in mortality on our WL for LT between 3 and 12 months after the inclusion. A simplified version of the MELD score, using only serum creatinine and INR might be taken into account when predicting 12 months mortality on WL with longer waiting time, but it has to be confirmed by other prospective studies.     

APACHEII模式联合MELD评分在预测活体肝移植围手术期预后中的作用

目的探讨APACHE(急性生理学和慢性健康评分)II模式联合MELD(终末期肝病模型)评分如何准确地评估活体肝移植围手术期预后。方法总结2006年6月至2009年5月在上海交通大学附属瑞金医院行活体肝移植术38例病人临床资料。结果围手术期存活组与死亡组病人的APACHE II分值分别为13.03±3.47和23.67±3.27;死亡风险度分别为(7.05±3.70)%和(25.07±9.34)%。两组病人的APACHE II分值、死亡风险度差异具统计学意义(P<0.001)。排除外科因素后APACHE II模式对预后的评估具有更好的准确性。MELD>25分与MELD<25分的病人预期病死率分别为(7.10±3.84)%和(15.11±11.93)%,差异具统计学意义(P<0.05)。APACHE II评分和MELD评分的接受者操作特征曲线(ROC)界值分别为20分和25分。结论应用APACHE模式对活体肝移植进行评估时应注意避免外科因素干扰;校正后APACHE II模式预测准确性更佳;APACHE II>20分或MELD>25分的病人预期病死率则显著增高。     

肝移植预后的影响因素和预测方法的临床进展

目的了解影响肝移植预后的因素以及可以预测肝移植预后方法的研究进展,为肝源的分配以及肝移植围术期的治疗提供指导和参考。方法检索PubMed、CNKI、万方等数据库中关于肝移植预后的影响因素以及预测其预后方法研究的相关文献并对此进行综述和分析总结。结果肝移植作为目前治疗终末期肝病的有效方法,影响肝移植预后的因素主要包括内环境的改变、全身炎症反应以及一般全身情况。在终末期肝病模型基础上结合血钠离子、乳酸、肌肉量以及网织红细胞计数和血红蛋白浓度建立的新预测模型提高了对肝移植预后的预测能力。结论结合影响肝移植预后的因素选择更有针对性的预测肝移植预后模型可能能更准确地预测肝移植患者预后,为围术期管理和治疗提供参考,使有限的肝源发挥最大的价值而挽救更多的生命。     

End-stage renal disease in liver transplants

Renal dysfunction is one of the most significant problems following orthotopic liver transplantation (OLTx). Since the major risk factor for delayed renal dysfunction following OLTx is presumed to be cyclosporine (CsA) nephrotoxicity, it has been suggested that CsA is the most probably cause of end-stage renal disease (ESRD) in this population of patients. To test this hypothesis the records of OLTx patients in our center who developed ESRD requiring dialysis were reviewed. There were 132 consecutive adult patients with end-stage liver disease (ESLD) who received 146 OLTxs between 1990 and 2000. Five patients (3.4%) developed ESRD requiring dialysis. Four of the five patients developed nephrotic range proteinuria prior to reaching ESRD. Renal biopsy in four patients showed focal segmental glomerulosclerosis, diabetic nephropathy, membranous nephropathy and cyclosporine toxicity. The underlying hepatic and metabolic disease may have played a role in the genesis of glomerular diseases in these OLTx patients. Perhaps if more renal biopsies are performed in OLTx patients with chronic renal failure, we might discover that, although CsA/tacrolimus therapy is a definite risk factor for post-transplantation chronic renal failure, other disease processes may also play a significant role.     

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.     

血浆置换在重型肝炎肝移植术前应用的临床观察

目的观察和评价术前血浆置换对重型肝炎肝移植的作用。方法回顾性分析连续35例接受原位肝移植的重型肝炎病人的临床资料,并按术前是否行血浆置换分为术前血浆置换组(PE组)19例和术前无血浆置换组(对照组)16例。观察PE组血浆置换前后临床生化指标及内毒素水平的变化;比较两组手术时间、出血量、输血量和应用血制品情况;对两组病人术后恢复过程、并发症生存率进行比较。结果PE组患者血浆置换后,肝功能生化指标明显好转,内毒素水平及血氨较置换前显著下降,凝血酶原时间、凝血酶原国际标化比值较置换前明显好转(P<0.01)。PE组患者手术时间明显缩短,出血量和输血量少于对照组。血浆置换组病人ICU住院时间短、胃肠功能恢复早,与对照组相比差异有显著性。血浆置换组病人呼吸道感染发生率、胆道并发症少于对照组,但差异无显著性;术后半年生存率血浆置换组为78.9%,对照组为56.3%,统计学也无显著性差异(P=0.273)。而死亡病例终末期肝病模型(MELD)评分显著高于生存组病例(P<0.01)。结论重型肝炎患者肝移植术前行血浆置换治疗能改善术前肝功能、凝血功能和减少术中出血。但血浆置换并不能降低围手术期并发症和提高存活率。     

Serum cholestasis markers as predictors of early outcome after liver transplantation

BACKGROUND: Early cholestasis is not uncommon after liver transplantation and usually signifies graft dysfunction. The aim of this study was to determine if serum synthetic and cholestatic parameters measured at various time points after transplantation can predict early patient outcome, and graft function. METHODS: The charts of 92 patients who underwent 95 liver transplantations at Rabin Medical Center between 1991 and 2000 were reviewed. Findings on liver function tests and levels of serum bilirubin, alkaline phosphatase (ALP), and gamma glutamyl transpeptidase (GGT) on days 2, 10, 30, and 90 after transplantation were measured in order to predict early (6 months) patient outcome (mortality and sepsis) and initial poor functioning graft. Pearson correlation, chi(2) test, and Student's t-test were performed for univariate analysis, and logistic regression for multivariate analysis. RESULTS: Univariate analysis. Serum bilirubin >/=10 mg/dL and international normalized ratio (INR) >1.6 on days 10, 30, and 90, and high serum ALP and low albumin levels on days 30 and 90 were risk factors for 6-month mortality; serum bilirubin >/=10 mg/dL on days 10, 30, and 90, high serum ALP, high GGT, and low serum albumin, on days 30 and 90, and INR >/=1.6 on day 10 were risk factors for sepsis; high serum alanine aminotransferase, INR >1.6, and bilirubin >/=10 mg/dL on days 2 and 10 were risk factors for poor graft function. The 6-month mortality rate was significantly higher in patients with serum bilirubin >/=10 mg/dL on day 10 than in patients with values of <10 mg/dL (29.4% vs. 4.0%, p = 0.004). Patients who had sepsis had high mean serum ALP levels on day 30 than patients who did not (364.5 +/- 229.9 U/L vs. 70.8 +/- 125.6 U/L, p = 0.005). Multivariate analysis. Significant predictors of 6-month mortality were serum bilirubin >/=10 mg/dL [odds ratio (OR) 9.05, 95% confidence intervals (CI) 1.6-49.6] and INR >1.6 (OR 9.11, CI 1.5-54.8) on day 10; significant predictors were high serum ALP level on day 30 (OR 1.005, 1.001-1.01) and high GGT level on day 90 (OR 1.005, CI 1.001-1.01). None of the variables were able to predict initial poor graft functioning. CONCLUSIONS: Several serum cholestasis markers may serve as predictors of early outcome of liver transplantation. The strongest correlation was found between serum bilirubin >/=10 mg/dL on day 10 and early death, sepsis, and poor graft function. Early intervention in patients found to be at high risk may ameliorate the high morbidity and mortality associated with early cholestasis.     

Model for the end-stage liver disease and death prediction in a cohort of Brazilian patients on the waiting list for liver transplantation

Abstract: Background/aim: To examine the performance of the model for end‐stage liver disease (MELD) score to predict mortality three and six months after enlistment of patients with chronic diseases for their first liver transplantation (LT) and to compare the performances of the Child–Turcotte–Pugh (CTP) and the Erasmus Model for End‐stage Resistant‐to‐therapy All etiology Liver Disease (EMERALD) scores with the MELD to predict mortality. Methods: Cohort study. Receiver operating characteristics curve (ROC) curves were used to determine the ability of the scores for predicting three and six month mortality, the c‐statistic to establish the predictive power of each score and the Cox proportional hazard model to estimate the risk of dying. Results: We studied 271 patients. At enlistment, the mean MELD and EMERALD scores were 14.8 and 26.6, respectively. Approximately 61% of the cases were in the CTP B category. During the three or six month follow‐up period, the percentage of patients dying, receiving LT or remaining on the list were 11.8%, 9.2%, and 79.0% or 19.2%, 17.7%, and 63.1%, respectively. The three‐month mortality was similarly predicted by the scores MELD, EMERALD and CTP (c‐statistic of 0.79, 0.74, and 0.70, respectively). Six‐month mortality presented similar AUC and ROC curves. Conclusion: The scores predicted mortality for the three or six months, but the performance of the MELD was better than CTP and EMERALD scores.     

Combined liver–kidney and liver transplantation in patients with renal failure outcomes in the MELD era

With the implementation of the Model for End-Stage Liver Disease (MELD) scoring system, the number of combined liver–kidney transplants (CLKT) has increased dramatically. The United Network for Organ Sharing (UNOS) dataset was analysed for adult recipients with renal failure for the period between February 2002 and April 2006. This group was subdivided into patients on hemodialysis (HD) and to those not on HD prior to transplantation. All recipients in renal failure (serum creatinine ≥2.5 mg/dl) at the time of transplantation were included. A total of 1397 subjects were in renal failure but not on HD (18% received a CLKT, 82% underwent LT alone). Another 1740 subjects were on HD prior to transplantation (41% received a CLKT while 59% received a LT). In dialysis-dependent recipients, Cox regression analysis demonstrated CLKT had an independent protective effect. In subjects on HD, CLKT had improved survival at 1 year (79.4 vs. 73.7%, P  = 0.004). In patients in renal failure without HD, CLKT was not protective.  CLKT subjects had a nonsignificant difference in survival as compared with patients who had undergone liver transplantation alone, at 1 year (81.0% vs. 78.8%, P  > 0.10). In subjects undergoing CLKT, there was improved survival at 1 year as compared with LT-alone patients on hemodialysis; however, in patients with renal failure, but not on hemodialysis, there was no difference in survival when comparing CLKT to LT-alone.     

Renal insufficiency after liver transplantation in the MELD era compared to the pre-MELD era

Abstract:  Because the model for end-stage liver disease (MELD) system for liver allocation gives priority to patients with a higher creatinine, and because pre-transplant renal function is one determinant of post-transplant renal function, this study compares the burden of renal insufficiency in the pre-MELD and MELD eras. Two hundred and elven patients, at our institution, transplanted in the pre-MELD era, were compared to 143 in the MELD era. The GFR (mL/min/1.73 m²) was significantly higher in the MELD cohort than the pre-MELD cohort at time of transplant, discharge, and 12 months post-transplant (95.5 vs. 85.3, p = 0.039; 90.4 vs. 77.4, p = 0.002; 66.8 vs. 60.3, p = 0.026). There was no difference between the two groups in time to renal failure. There was a higher rate of sirolimus use in the MELD era (27% vs. 18%: p = 0.042) and a slightly higher use of kidney–liver transplant in the MELD era (p = 0.056). We did not identify greater renal insufficiency in the MELD era. There was greater renal function in the MELD era at time of transplant, discharge and month 12. Potential explanations include: absence of an increase in renal insufficiency prior to transplant in the MELD era, greater use of renal sparing immunotherapy and growing use of kidney–liver transplant.     

Preshunt liver function remains the prominent determinant of survival after portasystemic shunting

BACKGROUND: Forty-five years after the development of the Child classification, we sought to determine if hepatic function is still a primary determinant between short-term and long-term survival after portasystemic shunting. METHODS: One hundred forty-six patients underwent small-diameter prosthetic H-graft portacaval shunting (HGPCS). The patients were stratified into 2 groups: those surviving less than 5 years and those surviving more than 5 years. Preoperative data determined Child class and model for end-stage liver disease (MELD) score. RESULTS: Ninety-four (64%) patients were short-term and 52 (36%) patients were long-term survivors. No significant differences in the cause of cirrhosis, presence of ascites, encephalopathy, or emergency operations were noted between short- and long-term survivors. Preshunt MELD scores were significantly greater with short-term survivors, although actual survival was superior to predicted survival by MELD. Child class was inferior for short-term survivors. Child class and MELD score significantly correlated with survival after portasystemic shunting. CONCLUSIONS: Long-term survival after HGPCS is possible even with severe hepatic dysfunction; however, actual survival is superior to predicted survival. Hepatic dysfunction, as denoted by Child class and MELD, still remains a primary determinant of survival after portasystemic shunting.     

儿童终末期肝病模型评分用于预测婴幼儿活体肝移植预后的作用

目的探讨儿童终末期肝病模型(PELD)评分系统用于预测婴幼儿活体肝移植预后的作用。方法回顾性分析2006年10月至2012年12月上海交通大学医学院附属仁济医院肝脏外科收治的101例小儿活体肝移植临床资料。患儿术前诊断均为胆道闭锁。术前对每例患儿进行PELD评分,根据PELD评分将患儿分为两组:低分组(PELD评分16分,62例)和高分组(PELD评分≥16分,39例)。比较两组患儿围手术期的基本情况及术后并发症发生率。结果两组患儿的手术年龄和体重差异均有统计学意义(均为P0.05),但两组性别、移植物(肝)重量/受体的体重、供肝冷缺血时间、术中失血量等差异均无统计学意义(均为P0.05)。PELD高分组患儿移植术后的肺部感染和胆道并发症发生率均明显高于低分组(均为P0.05)。结论术前PELD评分可用于预测婴幼儿肝移植的预后,为婴幼儿肝移植的围手术期的治疗、监护及护理措施的制定提供参考。对于术前PELD评分较高的患儿,应加强围手术期并发症的监护处理。     

终末期肝病模型评分及血清钠在肝衰竭近期预后判断中的意义

目的 比较基线及动态终末期肝病模型（MELD）及其联合血清钠（MELD-Na）在评价肝衰竭近期预后中的价值.方法 回顾性分析2003年4月至2012年4月新疆医科大学第一附属医院322例肝衰竭住院患者的资料,计算患者确诊时和一周后的MELD、MELD-Na评分,并计算△MELD 、△MELD-Na分值.应用受试者工作特征（ROC）曲线评价各评分系统预测患者3个月预后的价值,同时绘制Kaplan-Meier（K-M）生存曲线.结果 急性和亚急性、慢加急性、慢性肝衰竭患者3个月时的病死率分别为77.4％（24/31）,41.7％（50/120）和56.1％（96/171）,比较差异有统计学意义（x2=14.273,P ＜0.01）.对于急性和亚急性肝衰竭患者,各评分系统预测患者近期预后的ROC曲线下面积（AUC）为0.699～0.836,差异无统计学意义（Z=0.507,0.622,0.712,0.727,0.779,0.599,P＞0.05）.对于慢加急性肝衰竭,△MELD和△MELD-Na的AUC分别为0.889和0.897,均高于基线MELD和MELD-Na的AUC（Z=3.110和3.500,P＜0.05）,但△MELD和△MELD-Na的AUC比较差异无统计学意义（Z =0.310,P ＞0.05）;K-M生存曲线显示,当△MELD＞ 3.5分时,患者3个月内病死率为87.8％,平均生存时间为34.05 d.对于慢性肝衰竭,△MELD预测患者近期预后的AUC为0.871,优于△MELD-Na（Z=4.229,P＜0.05）;K-M生存曲线显示,当△MELD＞ 4.5分时,患者3个月内病死率为89.9％,平均生存时间为29.08 d.结论 对于急性和亚急性肝衰竭,各评分预测效果均可;对于慢加急性肝衰竭,△MELD和△MELD-Na均优于相应的基线评分系统;对于慢性肝衰竭,△MELD的预测能力最佳.     

The impact of disease recurrence on graft survival following liver transplantation: a single centre experience

Many diseases that cause liver failure may recur after transplantation. A retrospective analysis of the rate and cause of graft loss of 1840 consecutive adults receiving a primary liver transplant between 1982 and 2004 was performed to evaluate the rate of graft loss from disease recurrence. The risk of graft loss from recurrent disease was greatest, when compared to primary biliary cirrhosis (PBC), in those transplanted for hepatitis C virus (HCV) [hazard ratio (HR) 11.6; 95% confidence interval (CI) 5.1-26.6], primary sclerosing cholangitis (PSC) (HR 6.0; 95% CI 2.5-14.2) and autoimmune hepatitis (AIH) (HR 4.1; 95% CI 1.3-12.6). The overall risk of graft loss was also significantly greater in HCV (HR 2.1 vs. PBC; 95% CI 1.5-3.0), PSC (HR 1.6 vs. PBC; 95% CI 1.2-2.3) and AIH (HR 1.6; 95% CI 1.0-2.4) than in PBC. There was no statistically significant difference in the risk of graft loss because of recurrent disease, when compared with PBC, for patients transplanted for alcohol related liver disease, nonalcoholic steatohepatitis and fulminant hepatic failure. Disease recurrence is a significant cause of graft loss particularly in HCV, PSC and AIH. Recurrent disease, in part, explains the increased overall risk of graft loss in these groups.