Risk Factors for and Clinical Course of Non-Anastomotic Biliary Strictures After Liver Transplantation

Non-anastomotic biliary stricture (NAS) formation is a major complication of liver transplantation. We prospectively determined the time to development of responsiveness to treatment, and clinical outcomes following NAS formation. In addition, an extensive analysis of the association of recipient, donor, and clinical variables with NAS formation was performed. A total of 749 consecutive patients was studied in a prospective, protocol-based fashion. Seventy-two patients (9.6%) developed NAS at a mean of 23.6 +/- 34.2 weeks post-transplantation. Non-anastomotic biliary stricture formation resolved in only 6% of affected patients. Although patient survival was not affected, retransplantation and graft loss rates were significantly greater in recipients who developed NAS. In contrast to previous reports, a pretransplant diagnosis of HCV was associated with a low frequency of NAS formation. The incidence of NAS was independently associated with pretransplant diagnoses of PSC and autoimmune hepatitis. Hepatic artery thrombosis, and prolonged warm and cold ischemia times were also independent risk factors for NAS formation. We conclude that NAS developed in approximately 10% of primary liver transplant recipients. A pretransplant diagnosis of autoimmune hepatitis has been identified as a novel independent risk factor for NAS formation. Development of NAS significantly attenuates graft but not patient survival.     

Cardiovascular Risk Factors and Immunosuppressive Regimen After Liver Transplantation

Cardiovascular and metabolic diseases represent important long-term complications after liver transplantation (LT), impairing long-term and disease-free survivals. A few mechanisms underlie the development of those complications, but the role of immunosuppressive drugs is major. Although several patients develop temporary metabolic diseases, which normalize after a short postoperative period and do not need long-term drug therapy, the incidences of de novo long-lasting arterial hypertension, hyperlipidemia, and diabetes mellitus are high during the first year after LT. The aim of this retrospective study was to evaluate new-onset arterial hypertension, hyperlipidemia, or diabetes among 100 LT patients at a single institution. We used chi-square statistical analysis to compare incidences during tacrolimus versus cyclosporine therapy. Hypertension did not seem to be more strongly related to tacrolimus than to cyclosporine, nor did diabetes, whereas there was a difference for the development of hyperlipidemia.     

Risk Factors of Mortality After Liver Transplantation in Uruguay

Introduction

Identification of predictive factors of mortality in a liver transplant (LT) program optimizes patient selection and allocation of organs.

Risk Factors of Cytomegalovirus Infection After Pediatric Liver Transplantation

PurposeCytomegalovirus (CMV) infection is known to be the most frequently viral infection among patients after liver transplantation. This is especially true in pediatric living-donor liver transplantation because the recipients have often not been infected with CMV and postoperative primary infection with CMV frequently occurs.Patients and MethodsOf 93 patients who underwent pediatric liver transplantation at our department, 33 patients (36.3%) were diagnosed with CMV infection using the antigenemia method (C7-HRP). Retrospective review and statistical analysis were conducted to confirm risk factors of post-transplantation CMV infection.ResultPositive lymphocytes were diagnosed between postoperative days 8 and 111 after transplantation. Ganciclovir or foscavir were administrated to 21 patients. The other 10 patients who had one positive lymphocyte were observed and the cell disappeared on follow-up examination. We did not observe any cases of positive lymphocytes with C7-HRP in patients who received a graft from a CMV antibody?negative donor. Independent predictors associated with CMV infection in the multivariable analysis were administration of OKT3 and grafts from CMV antibody?positive donors.ConclusionIn CMV infection after pediatric liver transplantation, cases with CMV antibody?positive donors and with OKT3 administration for acute rejection are considered high risk, and cases with CMV antibody?negative donors are considered low risk.     

Incidence and Risk Factors of Deep Vein Thrombosis After Liver Transplantation

BackgroundDeep venous thrombosis (DVT) occurs in 0.1% of persons per year, affecting 15%–40% of general surgical procedures without prophylaxis. Thromboembolic prophylaxis is not commonly used after orthotopic liver transplantation (LT) owing to the risks of bleeding and coagulopathy. Cirrhosis and the association with the coagulation cascade, before and after transplantation, are not well understood. The purpose of this study was to determine the incidence of DVT and its risk factors after LT.MethodsWe retrospectively reviewed LTs performed at our center from 2005 to 2012. We identified patients with Doppler examinations showing DVT after LT, platelet count, and international normalized ratio (INR) at time of DVT, associated symptoms, DVT prophylaxis, and perioperative risk factors. We determined the incidence of DVT, the odds ratio of each preoperative risk factor, the difference in platelet count and INR between those with and without a DVT, and the weighted risk of each factor in the development of DVT with the use of logistic regression modeling.ResultsOf 314 patients, the incidence of DVT was 8.6% (27/314). Between those with and without DVT there was no significant difference in age, sex, platelet count, INR, infection, hepatocellular cancer, use of venous bypass, and prior surgery. There was a significant difference in mobility, 67% vs 20% (P < .0001), and the use of factor VII, 11% vs 2% (P < .05). The estimated risk for of developing DVT for patients with neither of these factors was 4%; with factor VII the risk rose to 17%; with mobility difficulty the risk rose to 23%; and with both the risk was 62%. In our entire population, there were no cases of pulmonary embolism.ConclusionsThe risk of developing a DVT after LT is ≥9% even with mechanical DVT prophylaxis. Consideration should be given to using both mechanical and chemical prophylaxis after LT.     

Risk Factors for Development of Acute Renal Failure After Liver Transplantation

Background.?Acute renal failure (ARF) is a common complication after liver transplantation (LTx). Identification of risk factors may prevent the development and attenuate the impact of ARF on patients outcome after LTX. Methods.?Retrospective analysis of variables in the pre, intra, and postoperative periods of 92 patients submitted to LTx was performed in order to identify risk factors for development of ARF after LTx. ARF was defined as serum creatinine ≥2.0 mg/dL in the first 30 days after LTx. Univariate and multivariate analysis by logistic regression were performed. Results.?ARF group comprised 56 patients (61%). Preoperative serum creatinine was higher in ARF group. During the intraoperative period, ARF group required more blood transfusions, developed more episodes of hypotension and presented longer anesthesia time. In the postoperative period, ARF group presented higher serum bilirubin and more episodes of hypotension. Dialysis was required in 10 patients (11%). The identified risk factors for development of ARF were: preoperative serum creatinine >1.0 mg/dL, more than five blood transfusions in the intraoperative period, hypotension during intra and postoperative periods. The identified mortality risk factors were hypotension in the postoperative period and no recovery of renal function after 30 days. Conclusions.?Several factors are involved in the pathogenesis of ARF after LTx and may influence patients outcome and mortality. Pretransplant renal function and hemodynamic conditions in the operative and postoperative periods were identified as risk factors for development of ARF after LTx. Nonrenal function recovery and postoperative hypotension were identified as mortality risk factors after LTx.     

Incidental Hepatocellular Carcinoma: Risk Factors and Long-Term Outcome After Liver Transplantation

Background

Orthotopic liver transplantation (OLT) currently represents the treatment of choice for early hepatocellular carcinoma (HCC). Preoperatively known HCC (pkHCC) is diagnosed via imaging methods before OLT or before HCC is found postoperatively in the liver explant, denoted as incidental HCC (iHCC). The aim of this study was a comprehensive analysis of the post-transplantation survival of patients with iHCC and the identification of risk factors of iHCC occurrence in cirrhotic liver.

Methods

We retrospectively reviewed 33 adult cirrhotic patients with incidentally found HCC, comparing them with 606 tumor-free adult cirrhotic patients with end-stage liver disease (group Ci) who underwent OLT in our center from January 1995 to August 2012. Within the same period, a total of 84 patients underwent transplantation for pkHCC. We compared post-transplantation survivals of iHCC, Ci, and pkHCC patients. In the group of cirrhotic patients (Ci + iHCC), we searched for risk factors of iHCC occurrence.

Results

There was no difference in sex, Model for End-Stage Liver Disease score, and time spent on the waiting list in either group. In the multivariate analysis we identified age >57 years (odds ratio [OR], 3.37; 95% confidence interval [CI], 1.75–8.14; P < .001), hepatitis C virus or alcoholic liver disease (OR, 3.89; 95% CI, 1.42–10.7; P < .001), and alpha-fetoprotein level >6.4 μg/L (OR, 6.65; 95% CI, 2.82–15.7; P = .002) to be independent predictors of iHCC occurrence. Both the 1-, 3-, and 5-year overall survival (OS) and the 1-, 3- and 5-year recurrence-free survival (RFS) differed in iHCC patients compared with the Ci group (iHCC: OS 79%, 72%, and 68%, respectively; RFS 79%, 72%, and 63%, respectively; vs Ci: OS = RFS: 93%, 94%, and 87%, respectively; P < .001).

Conclusions

The survival of iHCC patients is worse than in tumor-free cirrhotic patients, but similar to pkHCC patients. The independent risk factors for iHCC occurrence in cirrhotic liver are age, hepatitis C virus, or alcoholic liver disease etiology of liver cirrhosis and alpha-fetoprotein level.     

Risk Factors of Acute Renal Failure After Orthotopic Liver Transplantation: Single-center Experience

Background

Acute renal failure (ARF) is one of the most significant complications of orthotopic liver transplantation (OLT), associated with increased mortality rate and the development of chronic renal dysfunction. The aim of the study was to determine the perioperative risk factors for ARF in patients without previous history of renal disease who are undergoing OLT.

Materials and methods

Forty-six patients who developed ARF after OLT performed in 1 transplant center were included in the study, and 52 consecutive patients without that complication served as a control group. Renal dysfunction was defined as a glomerular filtration rate <60 mL/min/1.73 m². The data concerning preoperative diseases, perioperative renal function, first-line immunosuppressive therapy, and blood transfusion requirement were retrospectively analyzed and compared among groups. Logistic regression modeling was used to determine risk factors for ARF.

Results

Patients who developed ARF were significantly older (mean age 53.3 vs 46.3 years, P = .057), had higher level of preoperative (0.79 vs 0.71 mg/dL, P = .0062) and intraoperative (0.85 vs 0.74 mg/dL, P = .0045) creatinine. The risk factors for ARF were intraoperative and 24-hour post-transplant creatinine level >0.9 mg/dL and high-dose tacrolimus-based immunosuppression. Transfusion of ≤6 units of red blood cells diminished the risk of ARF. Sex and preoperative diseases were not predictive to ARF in our regression models.

Conclusion

Careful operative technique with low blood loss and immunosuppressive therapy of low nephrotoxic potential should be recommended in older patients to diminish the risk of renal dysfunction after orthotopic liver transplantation. Patients with higher levels of perioperative creatinine should be considered to have first-line immunosuppression without calcineurin inhibitors or with low-dose immunosuppressants of known nephrotoxic potential.     

Risk Factors for End‐Stage Kidney Disease After Pediatric Liver Transplantation

Adult liver transplant (LT) recipients commonly develop advanced kidney disease. However, burden of end‐stage kidney disease (ESKD) after pediatric LT has not been well‐described. We performed a retrospective cohort study of pediatric LTs in the United States from 1990 to 2010. Multivariable Cox regression models were fit to determine risk factors for ESKD and death. Eight thousand nine hundred seventy six children received LTs. During median follow‐up of 7.8 years, 2005 (22%) subjects died (mortality rate 26.1 cases/1000 person‐years); 167 (2%) developed ESKD (incidence rate 2.2 cases/1000 person‐years). Risk factors for ESKD included older age at LT (highest risk age >15 vs. < 5 years, HR = 4.94, p < 0.001), hepatitis C (HR 2.79, p = 0.004), liver re‐transplant (HR 2.67, p < 0.001), eGFR pre‐LT < 60 versus ≥ 60 (HR 2.37, p < 0.001), hepatitis B (HR 2.25, p = 0.027), black race (HR 1.46, p = 0.046), and male sex (HR 1.44, p = 0.022). LT recipients with ESKD had increased risk of mortality (HR 2.37, p < 0.001). Among pediatric LT recipients, rate of ESKD was lower than among adults and far exceeded by rate of death, however follow‐up time in this study may underestimate lifetime burden of ESKD. Although uncommon, ESKD was highly associated with mortality. Pediatric LT recipients should be routinely monitored for kidney disease, particularly those at highest risk of ESKD.     

Independent Risk Factors for Massive Ascites After Living Donor Liver Transplantation in Adults

Objectives

This study sought to define the perioperative recipient and donor factors that contribute to the occurrence of massive ascites after living donor liver transplantation (LDLT) in adults.

Methods

A retrospective review of medical records and computerized databases was performed, and 105 adult patients who underwent LDLT from 2005 to 2011 in the West China Hospital, Sichuan University, were included. Patients were divided into group 1 (n = 27, massive ascites defined as >7000 mL of ascitic fluid produced during the first 7 days after LDLT) or group 2 (n = 78, no massive ascites). Perioperative recipient and donor factors were assessed using a univariate analysis followed by 2 logistic regression analyses.

Results

The recipients' median age was 44 years (range, 27 to 69 years), and the male-to-female ratio was 92:13. Massive ascites developed in 27 patients (25.7%). The average amount of ascites in group 1 and group 2 patients within the first 7 postoperative days was 11,285 mL and 3311 mL, respectively. The univariate analysis showed that recipient's age, primary liver disease, preoperative MELD score, Child-Pugh score, operating time, postoperative sequential organ failure assessment (SOFA) score, postoperative total bilirubin, right hepatic vein graft diameter, and hepatic portal vein graft diameter were significantly different between the 2 groups (P < .05). The 2 logistic regressions showed that the Child-Pugh score, operating time, and right hepatic vein graft diameter were independent risk factors for massive ascites after LDLT.

Conclusion

It is important to improve the perioperative liver function and portal hypertension and to shorten operating time to reduce massive ascites after LDLT.     

Recipient-Related Preoperative and Intraoperative Risk Factors for Primary Graft Dysfunction After Orthotopic Liver Transplantation

Introduction

Primary graft dysfunction (PGD) is a multifactorial syndrome related to the most adverse outcomes after liver transplantation. Ischemia–reperfusion injury is recognized as the predominant cause of this complication. PGD may be subdivided into early allograft dysfunction, diagnosed by the presence of a serum bilirubin level ≥10 mg/dL (171 μmol/L), International Normalized Ratio ≥1.6, or alanine and aspartate transaminase levels ≥2000 IU/L on the seventh postoperative day; and primary nonfunction, defined as either a need for retransplantation or patient death within the first 7 days. We aimed to determine the preoperative and intraoperative risk factors for PGD.

Risk Factors for Depression After Kidney Transplantation

Objective

Kidney transplantation is recognized as the only potentially curative treatment for end-stage renal failure. But many psychiatric problems are associated with the procedure. The purpose of this study was to identify predictors of a risk for depression after kidney transplantation.

Materials and Methods

This retrospective cohort study recruited 116 first kidney-only Japanese recipients whose mean age was 50.2 ± 11.87 years include a male/female ratio of 63/53. They underwent transplantation between 1990 and 2008. At enrollment, we used the Zung Self-rating Depression Scale score as well as characterized demographic and clinical features of recipients and donors. Comparisons between depressed and non-depressed patients concerning sociodemographic and clinical characteristics were used χ² tests for categorical variables and Student's t-tests for continuous variables. Risk factors with significant correlation coefficients (P < .05) were entered into a stepwise logistic regression model to identify the best single risk factor for depression after kidney transplantation.

Result

The prevalence of depression in this study was 41.4%. Depressed patients were significantly more likely to not have regular incomes, nor to have desired kidney transplantation, to have experienced a rejection episode, and to live alone (P < .05). The single best predictor of future depression was living alone; subjects living alone were 2.51 times more likely to be depressed as those living with others (adjusted odds ratio [OR], 2.51; 95% confidence interval [CI], 1.31-5.22; P < .05).

Conclusion

Although depression after kidney transplantation is driven by multiple, complex, and often overlapping risk factors, we observed characteristic features of recipients including their social environment and follow-up treatment.     

Risk Factors Related to Early Biliary Complications After Liver Transplantation: a Single-Center Analysis

BackgroundThe aim of this study was to evaluate the risk factors of early biliary complications (EBC) after liver transplantation (LT) and seek effective treatments based on our single-center experience.MethodsA total of 124 adult patients were divided into a non-EBC group and EBC group. EBC usually accounts for biliary leakage, biliary stricture, biliary stones, sphincter of Oddi dysfunction, and transient jaundice within 3 months after LT. Statistical analysis including logistic regression was performed to determine EBC risk factors. All procedures complied with the Helsinki Congress and the Declaration of Istanbul.ResultsNon-EBC (n = 95) and EBC (n = 29) were finally compared, which had no difference in their general characteristics. EBC occurred in 29 patients (26.92%): 1 biliary hemorrhage (3.45%), 7 biliary leakage (24.13%), and 16 biliary stricture (55.18%), and 5 others (17.24%). Of all EBC patients, endoscopic retrograde cholangiopancreatography (68.96%) was higher used to deal with complications than conservative treatment (10.35%), percutaneous transhepatic cholangial drainage (17.24%), and surgical treatment (3.45%). On univariate analyses, risk factors for EBC were bilirubin (P = .014), warm ischemia time (WIT) (P = .020), second WIT (P = .042), and operative time (OT) (P = .033). On multivariate analysis, independent risk factors for BC were WIT (P = .011) and OT (P = .049).ConclusionsThe presence of WIT and OT were the independent risk factors for the development of EBC. In addition, we also confirmed that endoscopic retrograde cholangiopancreatography was beneficial and safe in the management of EBC after LT.     

Inflammatory Bowel Disease After Liver Transplantation: Risk Factors for Recurrence and De Novo Disease

Inflammatory bowel disease (IBD) is associated with primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH) and can recur or develop de novo after orthotopic liver transplantation (OLT). The aim of this study was to investigate the incidence and severity of IBD after liver transplantation and to perform a multivariate analysis for possible risk factors. In this retrospective study, 91 patients transplanted for PSC or AIH, without prior colectomy, were included. Sixty patients were transplanted for PSC, 31 for AIH. IBD activity before and after OLT and other possible risk factors were analysed in a multivariate model. Forty-nine patients (54%) had IBD before OLT. Forty patients (44%) had active IBD after transplantation: recurrence in 32 and de novo in 8. Cumulative risk for IBD after OLT was 15, 39 and 54% after 1, 5 and 10 years, respectively. In 59% of patients with IBD prior to OLT the disease was more active after transplantation. Risk factors for recurrent disease were: symptoms at time of OLT, short interval of IBD before OLT and use of tacrolimus. 5-aminosalicylates were protective. A cytomegalovirus positive donor/negative recipient combination increased the risk for de novo IBD.     

Epidemiology and Risk Factors for Cancer After Lung Transplantation

Cancer is the third most common cause of death among lung transplant (LT) recipients who survive for more than 1 year. The purpose of this study was to analyze the incidence and risk factors for cancer after LT in a Spanish cohort. The epidemiology and risk factors for cancer were retrospectively analyzed in LT recipients from 2 cities in Spain, Madrid and Barcelona. Of the 1353 LT patients initially included in the study, 125 (9.2%) developed cancer after a mean of 3.7 years. This frequency was 5-fold higher than in the general population. The most prevalent tumors were skin cancer (32%), lymphoproliferative disease (18%), and lung cancer (16.5%). In 4 patients, lung cancer was diagnosed on the day of the operation. The risk of cancer increased with age >55 year (hazard ratio [HR] 2.89 [1.64–5.09]; P < .001), in men (HR 2.8 [1.4–5.6]; P = .004), and in heavy smokers (>20 pack-years) (HR 2.94 [1.64–5.27]; P < .001). Other factors such as sun exposure were not found to be risk factors. In conclusion, prevalence of cancer is high in LT recipients in a Mediterranean country. Skin tumors, lymphoproliferative disease, and lung cancer are the most prevalent cancers. Age, male sex, and smoking were the main risk factors for cancer in this population.     

Obesity Risk Factors in Patients After Kidney Transplantation

Background

Kidney transplantation is currently the best approach for renal replacement therapy. Compared with dialysis, it provides a better quality of life and improves patient prognosis. However, some evidence suggests that body composition could play a role in the complications observed in kidney transplant recipients (KTRs), and may influence survival. The purpose of this study was to assess the eating habits and body composition of KTRs.

Risk Factors for Urinary Complications After Renal Transplantation

Urinary complications are common following renal transplantation. The aim of this study is to evaluate the risk factors associated with renal transplant urinary complications. We collected data on 1698 consecutive renal transplants patients. The association of donor, transplant and recipient characteristics with urinary complications was assessed by univariable and multivariable Cox proportional hazards models, fitted to analyze time-to-event outcomes of urinary complications and graft failure. Urinary complications were observed in 105 (6.2%) recipients, with a 2.8% ureteral stricture rate, a 1.7% rate of leak and stricture, and a 1.6% rate of urine leaks. Seventy percent of these complications were definitively managed with a percutaneous intervention. Independent risk factors for a urinary complication included: male recipient, African American recipient, and the "U"-stitch technique. Ureteral stricture was an independent risk factor for graft loss, while urinary leak was not. Laparoscopic donor technique (compared to open living donor nephrectomy) was not associated with more urinary complications. Our data suggest that several patient characteristics are associated with an increased risk of a urinary complication. The U-stitch technique should not be used for the ureteral anastomosis.     

Histopathologic Characteristics of Incidental Hepatocellular Carcinoma After Liver Transplantation

Introduction

Liver transplantation for patients with hepatocellular carcinoma (HCC) is an accepted therapeutic modality, depending on the size and number of nodules. Since a high incidence of incidental HCC at transplantation has been reported, our aim was to evaluate the histopathologic characteristics of these patients.

Patients and methods

This retrospective analysis from March 1998 to June 2009 included liver transplantation patients without increased alpha-fetoprotein or nodules on imaging methods. We included patients with HCC on anatomopathologic exam, excluding those presenting with HCC on the presurgery evaluation through clinical, laboratory and imaging methods.

Results

Among the 277 transplanted subjects, 27 showed incidental HCC. The alpha-fetoprotein average level was 8.52 mg/dL (1.6-28.2). One patient presented with adenomatosis and focus of HCC. Histopathologic analyses showed: mean tumor size was 0.9 cm (range = 0.4-3.5); average number of tumors in each explanted liver 1.85 (range = 1-7) nodules; and three (11.1%), microvascular invasion (11.1%). The TNM staging showed 17 (63%) stage I and 6 (22%) stage II. The Edmondson and Steiner classification showed 19 (70%) subjects in degree II.

Conclusion

The histopathologic presentation of incidental HCC after liver transplantation showed tumors in early stage with microvascular invasion in some cases.     

Risk Factors for Portal Vein Complications After Pediatric Living Donor Liver Transplantation With Left-sided Grafts

Purpose

Portal vein complications (PVC) after pediatric living donor liver transplantation (LDLT) have rarely been reported. We evaluated the long-term incidence and of the risk factors for PVC after pediatric LDLT.

Methods

From April 1997 to November 2008, 96 pediatric patients underwent LDLT using left lateral segments or left lobes. We investigated recipient factors, donor factors, and operative factors through medical records. The portal vein sizes in 96 recipients ranged from 2.7 mm to 13.0 mm (median = 5.0 mm). Portal vein reconstruction was usually performed with the graft portal vein anastomosed to the bifurcation of the recipient right and left portal veins, the so-called “branch patch”.

Results

PVC occured in 11 patients (11.5%) including early PVC (n = 3), late PVC (n = 8). The disease-free survivals at 1, 5, and 10 years after LDLT were 94.7%, 88.7%, and 86.0%. Upon univariate analysis, a portal vein size < 5 mm graft-to-recipient weight ratio (GRWR) ≥ 4%, transfusion volume ≥ 270 mL were significant risk factors for PVC. Body weight < 8 kg and previous operative history tendes to be adverse for PVC. Upon multivariate analysis by Cox regression, portal vein size < 5 mm was a highly significant factor for PVC after pediatric LDLT (hazard ratio = 5.627, P = .027).

Conclusion

The disease-free survival at 10 years after LDLT was 86.0%. If the recipient's portal vein size < 5 mm received a large-for-size graft (GRWR ≥ 4%), it is important to observe by regular Doppler ultrasonography follow-up to detect PVC.