No abstract

Donation after cardiac death liver transplantation is marred by inferior outcomes including higher rates of biliary complications and IC as well as increased mortality and graft failure. Despite current federal mandates to increase DCD donation, these serious complications translate into poor outcomes for individuals and increased healthcare costs. These risks should be considered in decisions regarding the utilization of these grafts.

Background & Aims: Frailty is associated with mortality in patients with cirrhosis. We measured frailty using 3 simple tests and calculated liver frailty index (LFI) scores for patients at multiple ambulatory centers. We investigated associations between LFI scores, ascites, and hepatic encephalopathy (HE) and mortality. Methods: Adults without hepatocellular carcinoma who were on the liver transplant waitlist at 9 centers in the United States (n=1044) were evaluated using the LFI; LFI scores of 4.5 or more indicated that patients were frail. We performed logistic regression analyses to assess associations between frailty and ascites or HE and competing risk regression analyses (with liver transplantation as the competing risk) to estimate subhazard ratios (sHR) of waitlist mortality (death or removal from the waitlist). Results: Of study subjects, 36% had ascites, 41% had HE, and 25% were frail. The odds of frailty were higher for patients with ascites (adjusted odd ratio, 1.56; 95% CI, 1.15-2.14) or HE (OR, 2.45; 95% CI, 1.80-3.33) than without these features. Higher proportions of frail patients with ascites (29%) or HE (30%) died while on the waitlist compared to patients who were not frail (17% of patients with ascites and 20% with HE). In univariable analysis, ascites (sHR, 1.52; 95% CI, 1.14-2.05), HE (sHR, 1.84; 95% CI, 1.38-2.45), and frailty (sHR, 2.38; 95% CI, 1.77-3.20) were associated with waitlist mortality. In adjusted models, only frailty remained significantly associated with waitlist mortality (sHR, 1.82; 95% CI, 1.31-2.52)-ascites and HE were not. Conclusions: Frailty is a prevalent complication of cirrhosis that is observed more frequently in patients with ascites or HE and independently associated with waitlist mortality. LFI scores can be Lai et al.

Background and Aims Organ scarcity has resulted in increased utilization of donation after cardiac death (DCD) donors. Prior analysis of patient survival following DCD liver transplantation has been restricted to single institution cohorts and a limited national experience. We compared the current national experience with DCD and DBD livers to better understand survival after transplantation. Methods We compared 1,113 DCD and 42,254 DBD recipients from the Scientific Registry of Transplant Recipients database between 1996 and 2007. Patient survival was analyzed using Kaplan-Meier methodology and Cox regression. Results DCD recipients experienced worse patient survival compared to DBD recipients (p<0.001). One and three year survival was 82% and 71% for DCD compared to 86% and 77% for DBD recipients. Moreover, DCD recipients required re-transplantation more frequently (DCD 14.7% versus DBD 6.8%, p<0.001), and re-transplantation survival was markedly inferior to survival after primary transplant irrespective of graft type. Amplification of mortality risk was observed when DCD was combined with cold ischemia time > 12hours (HR=1.81), shared organs (HR=1.69), recipient hepatocellular carcinoma (HR=1.80), recipient age >60 years (HR=1.92), and recipient renal insufficiency (HR=1.82). Conclusions DCD recipients experience signficantly worse patient survival after transplantation. This increased risk of mortality is comparable in magnitude to, but often exacerbated by other well-established risk predictors. Utilization decisions should carefully consider DCD graft risks in combination with these other factors.

No abstract

Sociocultural and socioeconomic disparities in graft survival, graft function, and patient survival in adult kidney transplant recipients are reviewed. Studies consistently document worse outcomes for black patients, patients with low income, and less education, whereas better outcomes are reported in Hispanic and Asian kidney transplant recipients. However, the distinct roles of racial/ethnic versus socioeconomic factors remain unclear. Attention to potential pathways contributing to disparities has been limited to immunological and nonimmunological factors, for which the mechanisms have yet to be fully illuminated. Interventions to reduce disparities have focused on modifying immunosuppressant regimens. Modifying access to care and health care funding policies for immunosuppressive medication coverage are also discussed. The implementation of culturally sensitive approaches to the care of transplant candidates and recipients is promising. Future research is needed to examine the mechanisms contributing to disparities in graft survival and to ultimately intervene effectively.

Living donor liver transplantation (LDLT) decreases the shortage of liver grafts for patients in need of a liver transplant, but it involves 2 patients: a recipient and a living donor. Despite the magnitude of the procedure for LDLT donors, only a few studies have investigated the effect of LDLT on the quality of life (QOL) of donors. We performed a systematic search of the MEDLINE database to identify peer-reviewed articles assessing QOL in adults after LDLT donation. Nineteen studies describing 768 unique donors met our inclusion criteria for this review. The median number of donors enrolled in each study was 30 (range ¼ 10-143), and the median follow-up period was 10.4 months (range ¼ 3-51.3 months). Before donation, donor QOL was significantly better than that in control adult populations across all measured QOL domains. Within the first 3 months after donation, the physical domains of QOL were significantly worse than the predonation levels, but they returned to baseline levels within 6 months for the majority of patients (80%-93%). Mental domains of QOL remained unchanged throughout the donation process. Common donor concerns after LDLT included bloating, loss of muscle tone, poor body image, and fatigue. In conclusion, according to our review of the existing literature, most LDLT donors return to their baseline QOL within 6 months. However, there is a lack of long-term data on donor QOL after LDLT, and few standardized assessments include measures of common patient concerns. Additional studies are necessary to develop a comprehensive risk profile for LDLT that includes a rigorous assessment of donor QOL. Liver Transpl 16:1352-1358,

Background and Aims. There are few long-term studies of health-related quality of life (HRQOL) in living liver donors. This study aimed to characterize donor HRQOL in the Adult to Adult Living Donor Liver Transplantation Study (A2ALL) up to 11 years post-donation. Methods. Between 2004-2013, HRQOL was assessed at evaluation, and 3 months and yearly post-donation in prevalent liver donors using the Short Form survey (SF-36), which provides a physical (PCS) and a mental component summary (MCS). Results. Of the 458 donors enrolled in A2ALL, 374 (82%) had SF-36 data. Mean age at evaluation was 38 (range 18-63), 47% were male, 93% white, and 43% had a bachelor’s degree or higher. MCS and PCS means were above the US population at all time points. However, at every time point there were some donors who reported poor scores (>1/2 standard deviation below the age and sex adjusted mean) (PCS: 5.3%-26.8%, MCS: 10.0%-25.0%). Predictors of poor PCS and MCS scores included recipient death within the two years prior to the survey and education less than a bachelor’s degree; poor PCS scores were also predicted by time since donation, Hispanic ethnicity, and at the 3-month post-donation time point. Conclusions. In summary, most living donors maintain above average HRQOL up to 11 years prospectively supporting the notion that living donation does not negatively affect HRQOL. However, targeted support for donors at risk for poor HRQOL may improve overall HRQOL outcomes for living liver donors.