The impact of pretransplant hepatic encephalopathy on survival following liver transplantation

Abstract

and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA Hepatic encephalopathy (HE) is a surrogate marker of liver disease severity, and more severe HE is associated with higher mortality among patients with chronic liver disease. However, whether severity of HE at the time of liver transplantation (LT) directly impacts post-LT survival or whether this suspected mortality linkage is due to more severe liver disease and subsequently higher rates of post-LT infection is not well defined. Using population-based data from the 2003 to 2013 United Network for Organ Sharing registry, we evaluated the impact of HE at the time of LT on post-LT survival among adults in the United States. Survival was stratified by HE severity (none, grade 1-2, grade 3-4) and Model for End-Stage Liver Disease score and was evaluated using Kaplan-Meier methods and multivariate Cox proportional hazards models. From 2003 to 2013, 59,937 patients underwent LT (36.1%, no HE; 53.8%, grade 1-2 HE; 10.2%, grade 3-4 HE). Compared to no HE, patients with grade 3-4 HE had significantly lower overall post-LT survival (1-year, 82.5% versus 90.3%; P < 0.001; 5-year, 69.1% versus 74.4%; P < 0.001). On multivariate regression, grade 3-4 HE was independently associated with lower overall post-LT survival (HR, 1.27; 95% CI, 1.17-1.39; P < 0.001). However, the increased mortality associated with HE is observed primarily within the first year following LT and was a reflection of higher rates of infection-related deaths among patients with more severe HE. In conclusion, grade 3-4 HE at the time of LT is associated with lower post-LT survival, with a proposed direct or indirect association of more severe HE before LT with increased rates of post-LT infections. Increased awareness and vigilance toward treating HE before LT and more aggressive monitoring and treatment for infections in the perioperative setting may improve LT outcomes. Liver Transpl 21:873-880, 2015. V C 2015 AASLD. February 26, 2015; accepted April 13, 2015. ReceivedThe implementation of the Model for End-Stage Liver Disease (MELD) score in the prioritization of patients awaiting liver transplantation (LT) is based on the principle of using objective criteria to offer LT to patients with the highest MELD score and thereby the sickest patients first.1,2 Although the MELD score performs well in predicting the risk of wait-list mortality, it does not incorporate the severity of hepatic Additional supporting information may be found in the online version of this article.

Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update

“…Mathurion et al [148] showed that in the absence of response to corticosteroid for AH as assessed by Lille score on day 7 and consideration of early LT lead to significant cumulative 6-month survival rate (77 ± 8% vs. 23 ± 8%, p < 0.001). In large UK and US cohort of severe autoimmune hepatitis showed that not the baseline MELD/UKELD but the use of corticosteroid and no improvement in MELD/ UKELD scores within 7 days had a poor outcome and suggested early consideration of other strategies including liver transplant [149][150][151][152]. A dynamic model that could predict the reversibility or need for liver transplant is urgently required.…”

Impact of Rifaximin Therapy on Ischemia/Reperfusion Injury in Liver Transplantation: A Propensity Score–Matched Analysis

“…Consistent with a previous report examining the protective effect of rifaximin against posttransplant infections, (27) our study showed that patients with pretransplant rifaximin treatment had a higher acuity level reflected by significantly higher MELD scores compared with controls. Another study by Wong et al (36) reported that patients with a history of HE had higher MELD scores compared with patients without HE. In the present study,…”

Impact of acute‐on‐chronic liver failure on 90‐day mortality following a first liver transplantation

“…Our findings corroborate the results of several other authors who studied the impact of a single organ failure on post‐LT outcomes. Cerebral failure defined by grade 3‐4 hepatic encephalopathy at the time of LT is associated with a lower post‐LT survival rate, and an association has been proposed between severe HE before LT and increased rates of post‐LT infections . Similarly, acute kidney injury at the time of LT has been associated with increased post‐operative morbidity and mortality .…”

“…Cerebral failure defined by grade 3-4 hepatic encephalopathy at the time of LT is associated with a lower post-LT survival rate, and an association has been proposed between severe HE before LT and increased rates of post-LT infections. 23 Similarly, acute kidney injury at the time of LT has been associated with increased post-operative morbidity and mortality. 24,25 As shown previously by Umgerter et al, the risk of mortality in these cirrhotic patients undergoing LT varied with the number of organ failures.…”