Autoimmune conditions are associated with perioperative thrombotic complications in liver transplant recipients: A UNOS database analysis

Abstract

BackgroundEnd stage liver disease (ESLD) is associated with significant thrombotic complications. In this study, we attempted to determine if patients with ESLD, due to oncologic or autoimmune diseases, are susceptible to thrombosis to a greater extent than patients with ESLD due to other causes.MethodsIn this retrospective study, we analyzed the UNOS database to determine the incidence of thrombotic complications in orthotopic liver transplant (OLT) recipients with autoimmune and oncologic conditions.Between 2000 and 2012, 65,646 OLTs were performed. We found 4,247 cases of preoperative portal vein thrombosis (PVT) and 1,233 cases of postoperative vascular thrombosis (VT) leading to graft failure.ResultsStatistical evaluation demonstrated that patients with either hepatocellular carcinoma (HCC) or autoimmune hepatitis (AIC) had a higher incidence of PVT (p = 0.05 and 0.03 respectively). Patients with primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC) and AIC had a higher incidence of postoperative VT associated with graft failure (p < 0.0001, p < 0.0001, p = 0.05 respectively). Patients with preoperative PVT had a higher incidence of postoperative VT (p < 0.0001). Multivariable logistic regression demonstrated that patients with AIC, and BMI ≥40, having had a transjugular intrahepatic portosystemic shunt, and those with diabetes mellitus were more likely to have preoperative PVT: odds ratio (OR)(1.36, 1.19, 1.78, 1.22 respectively). Patients with PSC, PBC, AIC, BMI ≤18, or with a preoperative PVT were more likely to have a postoperative VT: OR (1.93, 2.09, 1.64, 1.60, and 2.01, respectively).ConclusionDespite the limited number of variables available in the UNOS database potentially related to thrombotic complications, this analysis demonstrates a clear association between autoimmune causes of ESLD and perioperative thrombotic complications. Perioperative management of patients at risk should include strategies to reduce the potential for these complications.

Development of a Model to Predict Portal Vein Thrombosis in Liver Transplant Candidates: The Portal Vein Thrombosis Risk Index

“…Despite newer approaches, patient‐centered outcomes remain inferior in candidates with PVT in both the pretransplant and posttransplant settings with greater rates of hepatic decompensation, decreased posttransplant survival, and lower health‐related quality of life . Risk factors for incident PVT include reduced portal vein blood flow, severity of liver disease, hepatocellular carcinoma (HCC), and also etiology of liver disease (eg, nonalcoholic steatohepatitis [NASH] and autoimmune hepatitis) . Acquired hypercoagulability also plays a role in PVT development through elevated levels of prohemostatic factor VIII and decreased levels of the naturally occurring prohemostatic protein C, protein S, and antithrombin as well as heparin cofactor II .…”

“…(7)(8)(9)(10) Risk factors for incident PVT include reduced portal vein blood flow, severity of liver disease, hepatocellular carcinoma (HCC), and also etiology of liver disease (eg, nonalcoholic steatohepatitis [NASH] and autoimmune hepatitis). (11)(12)(13)(14)(15)(16) Acquired hypercoagulability also plays a role in PVT development through elevated levels of prohemostatic factor VIII and decreased levels of the naturally occurring prohemostatic protein C, protein S, and antithrombin as well as heparin cofactor II. (17) Rates of the Janus kinase 2 V6i7F mutation, the antiphospholid antibody syndrome, and the inherited factor V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase C677T mutations are also more prevalent in cirrhosis patients with PVT.…”

Liver transplant in patients with portal vein thrombosis: Medical and surgical requirements

“…The prevalence of PVT at the time of transplant evaluation or transplantation has historically been as high as 26% but is commonly reported as 5%‐12% in more recent series . An analysis of 65,646 liver transplant recipients in the United Network for Organ Sharing (UNOS) database from 2000 to 2012 revealed 4247 cases of preoperative PVT, an incidence of 6.5% . Patients without PVT at time of listing have a 1‐year de novo PVT rate of 7.4%‐8.4% .…”

“…Mortality may be as high as 17.5% in pretransplant patients with complete PVT . However, PVT does pose potential technical difficulty during liver transplantation and is associated with a doubling of risk of postoperative vascular thrombosis . Pretransplant PVT is an independent risk factor for graft loss due to an increased risk of hepatic artery thrombosis in liver transplant recipients .…”

“…(1)(2)(3) An analysis of 65,646 liver transplant recipients in the United Network for Organ Sharing (UNOS) database from 2000 to 2012 revealed 4247 cases of preoperative PVT, an incidence of 6.5%. (4) Patients without PVT at time of listing have a 1-year de novo PVT rate of 7.4%-8.4%. (5) Risk factors for pretransplant PVT include male sex, race/ethnicity, obese patients with a body mass index >40 kg/m 2 , diabetes mellitus, metabolic syndrome, nonalcoholic steatohepatitis, autoimmune hepatitis, hepatocellular carcinoma, and previously placed transjugular intraheptic portosystemic shunt (TIPS).…”