Prediction of survival after liver retransplantation for late graft failure based on preoperative prognostic scores

Abstract

The current policy for determining priority for organ allocation is based on the model for end stage liver disease (MELD). We hypothesize that severity of graft dysfunction assessed by either the MELD score or the Child-Turcotte-Pugh (CTP) score correlates with mortality after liver retransplantation (re-OLT). To test this hypothesis, we analyzed the outcome of 40 consecutive patients who received re-OLT more than 90 days after primary orthotopic liver transplantation (OLT). The Kaplan-Meier 1-year and 5-year survival rates after re-OLT were 69% and 62%, respectively. The area under the curve (AUC) values generated by the receiver operating characteristics (ROC) curves were 0.82 (CI 0.70-0.94) and 0.68 (CI 0.49-0.86), respectively (P ‫؍‬ .11), for the CTP and MELD models in predicting 1-year mortality after re-OLT. The 1-year and 5-year survival rates for patients with CTP scores less than 10 were 100% versus 50% and 40%, respectively, for CTP scores of at least 10 (P ‫؍‬ .0006). Patients with MELD scores less than or equal to 25 had 1-year and 5-year survival rates of 89% and 79%, respectively, versus 53% and 47%, respectively, for MELD scores greater than 25 (P ‫؍‬ .038). Other mortality predictors include hepatic encephalopathy, intensive care unit (ICU) stay, recurrent hepatitis C virus (HCV) infection, and creatinine level of 2 mg/dL or higher. Analysis of an independent cohort of 49 patients showed a trend for a correlation between CTP and MELD scores with 1-year mortality, with AUC of 0.59 and 0.57, in respective ROC curves. In conclusion, our results suggest that severity of graft failure based on CTP and MELD scores may be associated with worse outcome after re-OLT and provide a cautionary note for the "sickest first" policy of organ allocation. (HEPATOLOGY 2004;39:230 -238.)

Retransplantation for hepatitis C: Results of a U.S. multicenter retransplant study

“…MELD scores have been shown in other studies to predict posttransplantation survival. 9,19,24,25,28 In our study it was not predictive of survival in HCV patients partially due to low (3 yr) survival even in the moderate MELD score range. [20][21][22][23][24][25] Given the mean MELD score Ͼ25 at the time of evaluation for reTX, it is not surprising that these patients were often not offered a retransplant or could not survive long enough to get the organ they needed.…”

“…18,[21][22][23] The reported ability of MELD scores to predict post-reTX survival has been variable. 9,[24][25][26][27] In our study, although MELD scores were not predictive of post-reTX survival, higher MELD scores (particularly Ͼ25) at the time of reTX were associated with high post-reTX mortality. Overall post-reTX patient survival at 3 yr was 40 to 56% for patients with HCV infection regardless of MELD scores, whereas in non-HCV patients, the survival at 3 yr was below 60% only when the MELD score was above 30 (survival was 37%).…”

“…Those retransplanted within 1 yr of initial transplant had poorer survival (3-yr survival, 46%). Other studies have found many variables that may contribute to poorer survival including recurrent HCV, 14 ChildTurcotte-Pugh score, 25 hepatic encephalopathy, 25 intensive care stay, 14,28 poor renal function, 14,19,20,22,25,29,30 donor age, 11,14,17,20,27 prothrombin time, 11,20,25 time interval from initial transplantation, 14,27 recipient age, 14,20,22,25,27,30 ventilatory status, 6,20 bilirubin level, 6,14,19,20,22,29,30 physical condition, 31 and intraoperative blood loss. 22,30 Interestingly, many patients in this study had isolated variables or poor outcomes (51% had bilirubin Ͼ10 mg/dL and 25% had serum creatinine Ͼ 2 mg/dL).…”

Keeping high model for end‐stage liver disease score liver transplantation candidates alive

“…In general, transplant centers have considered a 50% 5-year survival to be an acceptable post-LT outcome after retransplantation. 56 For primary transplants, improvements in outcomes have resulted in a 75% 5-year patient survival in recent SRTR results and may have increased the threshold. 57 Because of the recent changes in the allocation system whereby more centers are transplanting sicker patients at higher MELD scores, the posttransplant survival expectations may decrease over time.…”

Analysis of 83 consecutive liver transplants performed at a tertiary care reference hospital in the interior of the state of Sao Paulo

“…This surgical procedure is highly complex for the treatment of preventable diseases such as cirrhosis due to complications of hepatitis B virus and hepatitis C virus and alcohol-induced cirrhosis in 80% of cases 2 . Patients submitted to a liver transplant have post-transplant 5-year survival rates ranging from 70 to 90% [3][4][5] .…”