The Predictors for Continuous Renal Replacement Therapy in Liver Transplant Recipients

Background

Acute renal failure (ARF) after liver transplantation requiring continuous renal replacement therapy (CRRT) adversely affects patient survival. We suggested that postoperative renal failure can be predicted if a clinically simple nomogram can be developed, thus selecting potential risk factors for preventive strategy.

Methods

We retrospectively reviewed the medical records of 153 liver transplant recipients from January 2008 to December 2011 at Severance Hospital, Yonsei University Health System, in Seoul, Korea. There were 42 patients treated with CRRT (20 and 22 patients received transplants from living and deceased donors, respectively) and 115 were not. Univariate and stepwise logistic multivariate analyses were performed. A clinical nomogram to predict postoperative CRRT application was constructed and validated internally.

Results

Hepatic encephalopathy (HEP; odds ratio OR, 5.47), deceased donor liver donations (OR, 3.47), Model for End-Stage Liver Disease (MELD) score (OR, 1.09), intraoperative blood loss (L; OR, 1.16), and tumor (hepatocellular carcinoma) as the indication for liver transplantation (OR, 0.11) were identified as independent predictive factors for postoperative CRRT on multivariate analysis. A clinical prediction model constructed for calculating the probability of CRRT post-transplantation was 1.7000 × HEP + [−4.5427 + 1.2440 × (deceased donor) + 0.0830 × (MELD score) + 0.000149 × the amount of intraoperative bleeding (L) − 2.1785 × tumor]. The validation set discriminated well with an area under the curve (AUC) of 0.90 (95% confidence interval, 0.85–0.95). The predicted and the actual probabilities were calibrated with the clinical nomogram.

Conclusions

We developed a predictive model of postoperative CRRT in liver transplantation patients. Perioperative strategies to modify these factors are needed.     

Impact of Donor and Recipient Age on Outcomes After Living Donor Liver Transplant

BackgroundLiving donor liver transplant between elderly donors and recipients has gained popularity, but the effects of their age remain unknown. Our aim is to evaluate the effects of matching by donor and recipient age with special insights into their recovery periods.MethodsNinety-five living donor liver transplant pairs, excluding the left lateral segment graft cases, who underwent surgery were enrolled. Median follow-up was 97 months (range, 1-212 months). Elderly recipients were classified as being 51 years or older. Donor-recipient pairs were divided into (1) nonelderly donor/nonelderly recipient (YY) (n = 26), (2) elderly donor/nonelderly recipient (n = 8), (3) nonelderly donor/elderly recipient (n = 38), and (4) elderly donor/elderly recipient (EE) (n = 23).ResultsThe 1-, 3-, and 5-year survival rates were 92.7%, 92.7%, and 88.9% (YY); 75.0%, 62.5%, and 62.5% (EY); 80.5%, 76.3%, and 67.9% (EY); and 86.9%, 82.6%, and 78.1% (EE) (P = .30), respectively. Perioperative parameters were comparable between the 4 groups. Liver grafts from the elderly population exhibited higher peaks of transaminases post-transplant regardless of recipient age (P ≤ .05). Postoperative recovery of total bilirubin in the EE group was relatively slower (P = .27). Required rates of plasma exchange postoperatively were relatively higher in the EE group (34.8% vs 15.4% in the YY group).ConclusionsThese findings suggest a modest and not statistically significant effect that elderly liver grafts exhibit slower recovery trajectories in the acute phase but finally achieve acceptable outcomes.     

Preemptive Therapy in Adult Liver Transplant Recipients in CMV-Endemic Area

Cytomegalovirus (CMV) infection is not only a common complication after liver transplantation but also a significant contributing factor to morbidity and mortality. We investigated whether preemptive therapy can prevent CMV syndrome or tissue-invasive CMV disease in an endemic area. Preemptive therapy was initiated when more than 10 positive CMV pp65 antigen-positive cells per 400,000 white blood cells were detected, regardless of clinical manifestations. Intravenous ganciclovir as preemptive therapy was administered daily for 10 to 14 days until negative results were achieved. The incidence of initial CMV antigenemia and CMV syndrome during the posttransplantation period was 49.7% (353/710) and 5.2% (37/710), respectively. One hundred eight-two patients (51.6%) received ganciclovir as preemptive therapy. Patients with CMV antigenemia who received preemptive therapy had high Model for End-Stage Liver Disease score, repeat operation, renal dysfunction, infection, low hemoglobin concentration, low platelet count, low albumin concentration, high international normalized ratio, high total bilirubin value, high aspartate transaminase concentration, and high CMV peak titer. Cytomegalovirus syndrome and tissue-invasive CMV disease were more common in these patients. The survival curve in patients without CMV syndrome was better than that in those with CMV syndrome (P = .000). Patients with more than 10 pp65 antigen-positive cells per 400,000 white blood cells should be treated aggressively with an antiviral agent as preemptive therapy because CMV infection is common in CMV-endemic areas and patients with CMV syndrome demonstrate poor survival rates.     

Single-center Experience of Living-donor Liver Transplantation in Patients Receiving Maintenance Renal Replacement Therapy

BackgroundFor most patients with liver failure receiving maintenance renal replacement therapy (RRT), treatment with living-donor liver transplantation (LDLT) alone is indicated in Japan.Material and MethodsWe retrospectively reviewed patients who underwent LDLT while receiving RRT in our hospital.ResultsThree of the 5 patients who underwent LDLT while on RRT died during the first year after transplantation.ConclusionsThe indications for liver transplantation in patients on RRT require careful examination.     

Analysis of Prognostic Factors for Patients Undergoing Renal Replacement Therapy With Acute Kidney Injury Prior to Living Donor Liver Transplantation

BackgroundAcute kidney injury (AKI) is a common complication in patients undergoing liver transplantation (LT) for end-stage liver disease (ESLD), and renal replacement therapy (RRT) is required in many cases. This study was performed to identify the prognostic factors for patients undergoing RRT owing to AKI before living donor liver transplantation (LDLT).Materials and MethodsFrom January 2010 to December 2018, LDLT was performed in 464 adult patients in our center. We reviewed 33 patients who underwent RRT before LDLT among 464 consecutive cases. Patients who continued to RRT after LDLT or who underwent subsequent kidney transplantation were considered to have not recovered from renal impairment.ResultsAmong 33 patients, there were 23 patients in the recovery group and 10 patients in the nonrecovery group. The preoperative duration of RRT was shorter in the recovery group, but it was not statistically significant. In the nonrecovery group, diabetes mellitus was found to have a higher prevalence and ischemic time was longer. Other perioperative factors were not significantly different between the 2 groups. After LDLT, the peak total bilirubin level was higher, and the intensive care unit stay was longer in the nonrecovery group. The overall survival rate was higher in the recovery group.ConclusionsLiver transplant recipients who maintain RRT after LDLT have poor outcome. It is necessary to know the risk factors and manage them well, perioperatively.     

Correlation Between Selected Prognostic Factors and Postoperative Course in Liver Transplant Recipients

Aim

The objective was to identify the major prognostic factors influencing liver function after transplantation that predict the postoperative course and long-term survival among liver transplant recipients. We analyzed the results of biochemical, microbiological, serologic, and pathologic studies of the donor and recipient, as well as intraoperative data.

Materials and methods

Of 542 liver transplant recipients, 215 (39.7%) were analyzed in the period from 1989 to 2006. Patients were divided according to the mechanism leading to the liver disease: group I, hepatitis C virus (HCV) infection (n = 80, 37.0%); group II, hepatitis B virus (HBV) infection (n = 33, 15.0%); group III, HBV and HCV infection (n = 13, 6.0%); group IV, alcoholic liver disease (ALD) (n = 66, 31.0%); and group V, autoimmune hepatitis (AIH) (n = 23, 11.0%).

Results

Prediction of patient survival based on clinical parameters showed a better prognostic value than that based only on liver function tests. Transplant urgency scores—Model for End-Stage Liver Disease (MELD), delta MELD and United Network for Organ Sharing (UNOS)—enabled us to predict early and long-term patient survival after liver transplantation. Update of these scores, reflecting the patient's condition, enabled us to evaluate pretransplant life-threatening factors and urgency level. Organ donation predictive factors were age, viral status, and degree of liver steatosis. Cold and warm ischemia times still were major prognostic factor. Routine biliary drainage resulted in worse long-term survival than non-drained patients. Liver transplantation for ALD showed the highest complication rate. Chronic liver rejection occurred more frequently in the AIH transplanted group. The most useful predictive factors for 1-year survival were urea/creatinine and liver function tests: aspartate and alanine aminotransferases, γ-glutamyl transpeptidase the International normalized ratio, and Quick.

Conclusion

The prognosis of patient outcomes after liver transplantation based on clinical parameters showed greater value than evaluation of the laboratory data.     

Intrauterine Growth Restriction in Pregnant Renal and Liver Transplant Recipients: Risk Factors Assessment

Background

Nowadays pregnancy after organ transplantation is possible due to advances in surgical and immunosuppressive therapies. One of the possible complications in pregnancy after organ transplantation is intrauterine growth restriction (IUGR). This may lead to various adverse perinatal outcomes. Prevalence of IUGR in the general population is estimated at 3%–10% with smoking being the most frequent maternal risk factor. The aim of this study was to determine the risk factors of IUGR in pregnant renal transplant recipients (RTR) or liver transplant recipients (LTR) in comparison with healthy pregnant women.

Methods

Retrospective analysis included 48 RTR and 52 LTR. IUGR was defined as estimated fetal weight less than the 10th percentile for gestational age. IUGR was diagnosed in 15 (31.3%) pregnant RTR and in 10 (19.2%) LTR. The control group consisted of 60 healthy pregnant women diagnosed with IUGR. Fisher exact test and Student t test were used to assess the differences in fractions and means, respectively, between distinguished groups of patients. Test for fractions based on asymptotic normal distribution was used to compare the proportion of patients with IUGR with the proportion of 10% in the general population. The logistic regression model was used to assess the statistical significance of correlations between the assumed risk factors and the prevalence of IUGR in multivariate settings.

Results

Hypertension, anemia, and proteinuria were the most frequent complications in the study group. They were more prominent in RTR than in LTR. Hypertension was diagnosed in all RTR, whereas severe anemia requiring erythropoietin treatment or blood transfusion was found in 4 RTR and in 1 LTR.

Conclusion

IUGR is more common in organ recipients. Therefore, vigilant obstetric care is highly recommended in pregnant patients after renal or liver transplantation. Hypertension, severe anemia, and proteinuria proved not to be statistically significantly correlated with the prevalence of IUGR among patients after transplantation.     

Impact of Donor Age and Year of Transplant on Graft Survival in Liver Transplant Recipients with Chronic Hepatitis C

Studies suggest donor age and year of transplantation are associated with low graft survival in liver transplant recipients with hepatitis C. We sought to determine if advanced donor age and recent year of transplantation are associated with graft survival in hepatitis C recipients and to determine if the effect of donor age on graft survival is specific to hepatitis C. We analyzed the United Network for Organ Sharing liver transplant database from 1994 to 2002. Six thousand four hundred and four subjects transplanted for end-stage liver disease from chronic hepatitis C met our criteria. One-year graft survival in hepatitis C recipients with organs from donors <40 years old and >or=60 years old was 84% and 73%, p = 0.003, respectively. These rates in recipients with cholestatic liver disease and alcoholic liver disease were 85% and 82%, respectively, p = 0.11 and 82% and 78%, respectively, p = 0.14. Three-year graft survival in hepatitis C recipients transplanted from 1994 to 1995 and 1996 to 1999 was 67% and 69%, respectively, p = 0.10. Graft survival in hepatitis C recipients has not declined in recent years. Older donor age is associated with lower short-term graft survival in recipients with hepatitis C, but not in recipients with cholestatic or alcoholic liver disease.     

Impact of Enterococcal Bacteremia in Liver Transplant Recipients

BackgroundEnterococcus species are a common cause of bacteremia in liver transplant recipients. Vancomycin-resistant enterococci (VRE) have become an important cause of nosocomial infection. In this study, we analyzed the incidence, antibiotic resistance, and outcomes of enterococcal bacteremia in living donor liver transplant recipients and the risk factors for VRE.Patients and MethodsThis single-center, retrospective review included 536 patients who underwent liver transplant between January 2008 and December 2017.ResultsAmong 536 patients, 42 (7.8%) experienced a total of 58 enterococcal bacteremic episodes (37 Enterococcus faecium, 17 Enterococcus faecalis, 2 Enterococcus casseliflavus, 1 Enterococcus. avium, and 1 Enterococcus raffinosus). Most cases of enterococcal bacteremia (46/58, 79.3%) occurred within 6 months after transplant; among the 26 cases of VRE bacteremia, 50% occurred within 1 month after transplant. E. faecium isolates had the highest rate of vancomycin resistance (25/37, 67.5%), whereas all E. faecalis isolates were susceptible to vancomycin. According to multivariate analysis, post-transplant dialysis (odds ratio, 3.95; 95% CI, 1.51–10.34; P = .005) and length of post-transplant hospital stay (odds ratio, 1.03; 95% CI, 1.009–1.04; P = .004) were significantly associated with VRE bacteremia. One-year mortality was 31% (13/42) among recipients with enterococcal bacteremia, 5.0% (20/384) among nonbacteremic patients, and 11.1% (10/90) among patients with nonenterococcal bacteremia (P < .001).ConclusionIn this study, enterococcal bacteremia showed high incidence in liver transplant recipients, especially with vancomycin resistance, occurred in early period after transplant, and was associated with increased mortality. High rates of resistance to vancomycin warrant further efforts to manage enterococcal infection in liver transplant recipients at our center.     

Incisional Hernia in Recipients of Adult to Adult Living Donor Liver Transplantation

Background

After receiving a living donor liver transplant (LDLT), an incisional hernia is a potentially serious complication that can affect the patient’s quality of life. In the present study we evaluated surgical hernia repair after LDLT.

Materials and methods

Medical records of patients who underwent surgery to repair an incisional hernia after LDLT in Turgut Ozal Medical Center between October 2006 and January 2010 were evaluated in this retrospective study. A reverse-T incision was made for liver transplantation. The hernias were repaired with onlay polypropylene mesh. Age, gender, post-transplant relaparatomy, the type, the result of surgery for the incisional hernia, and risk factors for developing incisional hernia were evaluated.

Results

An incisional hernia developed in 44 of 173 (25.4 %) patients after LDLT. Incisional hernia repair was performed in 14 of 173 patients (8.1 %) who underwent LDLT from October 2006 to January 2010. Relaparatomy was associated with incisional hernia (p = 0.0002). The mean age at the time of the incisional hernia repair was 51 years, and 79 % of the patients were men. The median follow-up period was 19.2 (13–36) months after the hernia repair. Three patients with intestinal incarceration underwent emergency surgery to repair the hernia. Partial small bowel resection was required in one patient. Postoperative complications included seroma formation in one patient and wound infection in another. There was no recurrence of hernia during the follow-up period.

Conclusions

The incidence of incisional hernia after LDLT was 25.4 % in this study. Relaparatomy increases the probability of developing incisional hernia in recipients of LDLT. According to the results of the study, repair of an incisional hernia with onlay mesh is a suitable option.     

Impact of a Donor Age >75 Years on the Survival of Liver Transplant Recipients

BackgroundAn organ shortage is the reason why it is necessary to expand the pool of donors, which can be achieved by using elderly donors. The main goal of this study is to analyze the outcomes of liver transplant (LT) when it is performed with donors older than 75 years.MethodsWe carried out a retrospective case-control study (N = 212) that included LTs with donors older than 75 years (group A, n = 106 cases) that were performed in our center between the years 2010 and 2020. This cohort has been paired off with a similar control group (group B, n = 106) whose donors were significantly younger. A survival analysis using the Kaplan-Meier model was performed.ResultsAverage (SD) age of donors in group A was statistically greater than group B (A, 79.1 [3.0] years vs B, 54.4 [15.3], P < .001). There were no differences either in the average age of the recipients or in the Model for End-Stage Liver Disease score of both groups. Indications for LT were distributed equally in both groups: the most common was cellular hepatocarcinoma followed by alcohol-related cirrhosis. Survival rates for group A were 81%, 78%, and 67%, in 1, 3, and 5 years, respectively, while in group B they were 85%, 76%, and 71%, respectively, without differences found between the groups (P = .57).ConclusionsUsing elderly liver donors is safe, achieving good outcomes in terms of short- and midterm rates of survival.     

Optimizing Risk Assessment In Simultaneous Liver and Kidney Transplant: Donor and Recipient Factors Associated With Improved Outcome

Standardization in allocation of kidneys for transplant simultaneous with livers and the creation of a “safety net” for kidney transplant after liver transplant alone (LTA) was designed to encourage clinicians to list patients for LTA when the likelihood of renal recovery and the necessity of simultaneous liver and kidney (SLK) transplant were unclear. We analyzed the United Network for Organ Sharing database of SLK recipients starting January 1, 2015. Organs from one deceased donor were used in each individual case. Univariate analysis was used to analyze recipient and donor characteristics against patient and graft survival of at least 1 year. Cox regression was employed for multivariable analysis controlling for donor risk index variables. SLK recipients who failed to achieve 1 year of post-transplant survival were more likely to be older, have higher model for end-stage liver disease scores, have diabetes, have received dialysis within one week of transplant, and required intensive care unit admission at transplantation. Patients who failed to survive for at least 1 year after SLK were more likely to have received organs from donors who were older with a higher kidney donor profile index. Using national data we identified SLK donor and recipient characteristics associated with poor post-transplant outcome. Clinicians involved in the decision to list patients with liver failure for LTA or SLK may use these associations to help guide decision making.     

Prophylaxis and Treatment of Chagas Disease in Renal Transplant Donor and Recipient: Case Report

Chagas disease is a prevalent zoonosis in Latin America, caused by the protozoa Trypanosoma cruzi and transmitted by Triatoma infestans. Part of the infectious cycle consists of chronic subclinical parasitemia, causing in the long term end-organ damage. Amastigotes have been isolated from various organs including native and allograft renal parenchyma; thus, transplantation plus immunosuppression therapy is another mode of disease transmission and reactivation. Herein, we report 2 successful kidney transplantations cases in which either infection or reactivation was averted using prophylactic nitroderivates.     

Osteoporosis and Related Risk Factors in Renal Transplant Recipients

Decreased bone mineral density is a common problem after kidney transplantation. Osteoporosis has a major role in morbidity in these patients. We evaluated the incidence of osteoporosis and determined risk factors in 77 patients aged 17 to 50 years who had undergone renal transplantation 6 months to 2 years previously. Bone mineral densitometry was performed using dual-energy x-ray absorptiometry. The incidence of osteoporosis was 26% (20 of 77 patients). Mean (SD) age of affected patients was 34.6 (8.7) years. The most common sites of osteoporosis were the hip (osteoporotic in 19 patients [24.7%] and osteopenic in 42 [54.5%]) and the spine (osteoporotic in 6 patients [7.8%] and osteopenic in 52 [67.5%]). There was a significant relationship between posttransplantation creatinine concentration and hip osteoporosis (P = .01). No relationship was observed between osteoporosis and age, sex, body mass index, duration of hemodialysis therapy, cumulative dosage of any drugs, or use of pulsed methylprednisolone therapy. A hip or spine z score of 1 or less had no relationship to the number of steroid pulse sessions but was significantly related to the total dosage of cyclosporine (P < .001), prednisolone (P < .001), and mycophenolate mofetil (P < .05). A hip z score of less than 1 was related to the posttransplantation period (P = .02). In conclusion, osteoporosis is a frequent complication that requires detection and treatment to reduce morbidity.     

Cytomegalovirus Infection Renal Transplant Recipients: Risk Factors and Outcome

Objective

Cytomegalovirus (CMV) is the most common viral infection after allotransplantation; it can be a major cause of morbidity and mortality. Our aim was to analyze the main risk factors that lead to development of CMV infection and disease.

Patients and Methods

We retrospectively analyzed 207 patients who received a renal allograft from May 2003 to December 2007. Three patients (D−/R−) were excluded. CMV infection was defined by the detection of 2 or more positive tests for pp65 antigenemia and CMV disease by evidence of attributable symptoms in need of antiviral treatment.

Results

Thirty-two patients (15.7%) presented active CMV infections and another 35 (17.2%), CMV disease. The mean follow-up was 27.8 ± 17 months. Prior to transplantation, 9.2% of patients were seronegative (D+/R−) and 77.9% seropositive (D+/R+). Compared with noninfected patients, those with CMV infection/disease were older and received an allograft from an older donor. Upon logistic regression analysis, recipient age older than 55 years, induction therapy with Thymoglobulin, and maintenance immunosuppression with cyclosporine were the major risk factors to develop CMV disease. An early acute rejection episode was more frequent and renal function measured by serum creatinine poorer until 18 months posttransplantation among CMV-infected versus noninfected patients.

Conclusions

Our data showed that CMV infection is a common complication after kidney transplantation associated with older age, induction treatment with antilymphocyte globulin, worse renal function, and increased patient morbidity.     

Donor and Recipient Factors Predicting Time to Graft Failure Following Orthotopic Liver Transplantation: A Transplant Risk Index

Introduction

Much of the success of a transplant depends on appropriate matching of donor to recipient.

Methods

We validated the Donor Risk Index formula (DRI) using Mount Sinai Medical Center's 10-year cohort of over 1000 transplants.

Results

The DRI was significantly associated to graft failure with a relative risk (RR) of 1.32. Our cohort had an average DRI of 2.6 with survival of 83% at 3 months, 79% at 1 year, and 70% at 3 years. The low rate of graft failure at a high DRI implies that there are other factors important in transplant pairing that are not considered in the DRI model. To determine these variables and quantify their importance, we constructed a Transplant Risk Index by identifying recipient and donor variables not captured in United Network for Organ Sharing (UNOS) that significantly correlated to graft failure. The most significant independent predictors of time to graft failure were donor age, weight, and peak serum sodium; ischemia time; and recipient creatinine, international normalized ratio, and hepatitis C infection. The coefficients for each of these factors were compiled into a Transplant Risk Index formula. A cutoff of 5 resulted in a graft survival rate of 86% at 3 months, 76% at 1 year, and 62% at 3 years using Kaplan-Meier analysis. The predictive ability of the Transplant Risk Index was greater than the DRI or DMELD (the product of donor age and preoperative MELD) as assessed by the area under the receiver operating curve and the positive and negative predictive values.

Conclusion

The Transplant Risk Index captures recipient factors and donor factors not captured in UNOS. Including these factors may improve the ability to predict good donor–recipient pairing.