Evaluating twenty-years of follow-up after orthotopic liver transplantation, best practice for donor-recipient matching: What can we learn from the past era?

Abstract

AIMTo characterize major determinants of 20-year survival after liver transplantation (LT).METHODSThis longitudinal single-institution study includes 313 consecutive patients who received a LT between 1988 and 1992. Pretransplant clinical characteristics and laboratory values were assessed and compared between 20-year survivors and non-survivors. Particular attention was paid to the Model for End-Stage Liver Disease (labMELD)-score and the Eurotransplant Donor Risk Index (ET-DRI) to unravel their impact on 20-year survival after LT.RESULTSTwenty-year survivors were significantly younger (44 vs 50 years, P = 0.001), more likely to be female (49% vs 36%, P = 0.03) and less likely to be obese at the time of LT (19% vs 32%, P = 0.011). Mean labMELD-score (P = 0.156), rate of high-urgency LT (P = 0.210), cold-ischemia time (P = 0.994), rate of retransplantation (P = 0.12) and average donor age (28 vs 33 years, P = 0.099) were not statistically different. The mean estimated glomerular filtration rate was higher among survivors (P = 0.007). ET-DRI > 1.4 (P = 0.020) and donor age ≥ 30 years (P < 0.022) had significant influence on 20-year survival. The overall survival was not significantly impacted by labMELD-score categories (P = 0.263).CONCLUSIONLT offers excellent long-term results in case of optimal donor and recipient conditions. However, mainly due to the current organ shortage, these ideal circumstances are rarely given; thus algorithms for donor-recipient matching need to be refined, in order to enable a maximum benefit for the recipients of high quality as well as marginal organs.

The donor risk index: A decade of experience

“…The C‐statistic was 0.61 in validation . Survival differences were predominantly driven by events in the first year . However, later validation studies assigned a lower C‐statistic of 0.48‐0.52 .…”

Prognostic role of the Donor Risk Index, the Eurotransplant Donor Risk Index, and the Balance of Risk score on graft loss after liver transplantation

“…All included studies were retrospective cohort analyses conducted in Europe, Asia, Africa, South America, Canada, and the United States between 2006 and 2020 [3,7–11,20–22,24–53]. A total of 35 580 liver transplant patients were included in the DRI meta‐analysis, and 11 666 liver transplant patients were included in the ET‐DRI meta‐analysis (Tables 1 and 2).…”

“…Thirty-four retrospective studies assessed the effect of DRI on 3-month, 1-year, and 3-year graft loss [3,[7][8][9]11,20,21,[24][25][26][27][28][29][30][31][33][34][35][36][37][38][39][40][41][43][44][45][46][48][49][50][51][52][53]. Seven studies evaluated the relationship between ET-DRI and 3-month, 1-year, and 3-year graft loss [9,10,[20][21][22]32,42]. Two studies evaluated the effect of the BAR score on 3-month and 1-year graft loss [23,24].…”

“…In the remaining 29 studies (97%), high applicability concerns were observed only in the domain "Outcomes" [11,20,[26][27][28][29]31,[33][34][35][36][37][38][39]41,[43][44][45][46][48][49][50][51][52][53][55][56][57]. According to PROBAST, seven studies included in the ET-DRI analysis were rated low risk of bias, and one was rated high risk of bias [9,10,[20][21][22]32,42,58]. In the study by Winter et al, the domain "Participants' was rated high risk of bias [21].…”

“…In the study by Winter et al, the domain "Participants' was rated high risk of bias [21]. Five studies had low applicability concerns, and three studies had high applicability concerns in the domain "Outcomes" [10,32,42]. Nine studies included in the BAR score analysis were rated low risk of bias [10,20,23,24,[59][60][61][62][63].…”