A nomogram to predict survival in patients with acute-on-chronic hepatitis B liver failure after liver transplantation
Liang ChenJiebin ZhangTongyu LuJianye CaiJun ZhengJia YaoShuhong YiHua LiGuihua ChenHui ZhaoYingcai ZhangYang� Yang
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Background: Individualized prediction of survival after liver transplantation (LT) for patients with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) has not been well investigated. This study aimed to develop a prognostic nomogram for patients with HBV-ACLF undergoing LT.Methods: The nomogram was derived from a retrospective study of 290 patients who underwent LT for HBV-ACLF at the Third Affiliated Hospital of Sun Yat-sen University between January 2012 and December 2017. Concordance index and determiner calibration curve was used to ascertain the predictive accuracy and discriminative ability of the nomogram. The predictive performance of the nomogram was compared with that of Child-Pugh score, model for end-stage liver disease (MELD), MELD-Na, chronic liver failure Consortium Organ Failure score (CLIF-C OFs), and CLIF-C ACLF.Results: The 1-year mortality rate was 23.1% (67/290). The Cox multivariate analysis showed that risk factors for 1-year survival rate included white blood cell count, alanine aminotransferase/aspartate aminotransferase ratio, and the organ failure numbers. The determiner calibration curve showed good agreement between prediction of the nomogram and actual observation. The concordance index of the nomogram for predicting 1-year survival was 0.707, which was significantly higher than that of other prognostic models: Child-Pugh score (0.626), MELD (0.627), MELD-Na (0.583), CLIF-C OF (0.674), and comparable to that of CLIF-C ACLF (0.684).Conclusions: Our study developed a novel nomogram that could accurately predict individualized post-transplantation survival in patients with HBV-ACLF. The nomogram might be a useful tool for identifying HBV-ACLF patients who would benefit from LT.Keywords:
Nomogram
Concordance
Liver disease
Key Points 1 How do physicians decide which patients with pulmonary vascular disease will benefit from liver transplantation? 2 Studies on patients with pulmonary vascular disease are limited and the findings and recommendations may not apply to all practice sites. 3 All patients with hypoxemia, liver disease, and pulmonary vasodilation do not have hepatopulmonary syndrome (HPS). 4 Not all patients with hepatopulmonary syndrome will benefit from liver transplantation. 5 The mean pulmonary artery pressure (mPAP) may not be an accurate predictor of mortality in patients with portopulmonary hypertension. 6 The effects of pulmonary vasodilators on the outcome of patients with portopulmonary hypertension (PPHTN) is still unconfirmed but promising. (Liver Transpl 2004;10:S54–S58.)
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Hepatopulmonary syndrome (HPS) is associated with increased waitlist mortality in liver transplantation (LT) candidates. Children with HPS are granted Model for End-Stage Liver Disease (MELD)/Pediatric End-Stage Liver Disease (PELD) exception points for waitlist prioritization in the United States based on criterion developed for adults. In this study, the impact of this MELD/PELD exception policy on post-LT survival in children was examined. A retrospective cohort of patients aged younger than 18 years with a MELD/PELD exception request who underwent LT between 2007 and 2018 were identified in the Scientific Registry of Transplant Recipients. Patients were stratified by waitlist partial pressure of arterial oxygen (PaO 2 ) to assess risk factors for waitlist mortality and post-LT survival. Among 3082 pediatric LT recipients included in the study, 124 patients (4%) received MELD/PELD exception points for HPS. Patients with HPS were a median age of 9 years (interquartile range: 6, 12 years), 54.8% were girls, and 54% were White. Most patients (87.9%) were listed with laboratory MELD/PELD scores <15. Waitlist mortality for patients with HPS exception points was rare and not different from patients without HPS. When stratified by pre-LT PaO 2 , hypoxemia severity was not associated with differences in 1-, 3-, or 5-year survival rates after LT ( p = 0.13). However, patients with HPS showed a slightly lower survival rate at 5 years compared with patients without HPS (88.7% vs. 93.4%; p = 0.04). MELD/PELD exceptions for children with HPS mitigated waitlist mortality, and recipients with HPS experienced excellent 5-year survival after LT, although slightly lower than in patients without HPS. Unlike adults with HPS, the severity of pre-LT hypoxemia in children does not impact post-LT survival. These data suggest that adult criteria for granting MELD/PELD exception points may not appropriately capture HPS severity in pediatric patients. Further prospective multicenter studies to examine the risk factors predicting negative survival outcomes in children with HPS are warranted.
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Liver disease
Alcoholic Hepatitis
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As the mean Model for End-Stage Liver Disease (MELD) score at time of liver transplantation continues to increase, it is crucial to implement preemptive strategies to reduce wait-list mortality. We review the most common complications that arise in patients with a high MELD score in an effort to highlight strategies that can maximize survival and successful transplantation.
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With an advance in liver transplantation, patients should be managed with a thorough knowledge of the pathophysiology and pharmacology of liver disease The action of anesthetic drugs on the diseased liver or the special circumstances of this operation have been under investigation. This article focuses on recent observations in advanced liver disease and liver transplantation.
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The classical form of alpha-1-antitrypsin deficiency (A1ATD) is known to cause liver disease in children and adults, but there is relatively little information about the risk of severe, progressive liver disease and the need for liver transplantation. To better understand how newly evolving pharmacological, genetic, and cellular therapies may be targeted according to risk for progressive liver disease, we sought to determine the age distribution of A1ATD as a cause of severe liver disease, as defined by the need for liver transplantation. Using 3 US liver transplantation databases for the period 1991-2012, we found 77.2% of 1677 liver transplants with a reported diagnosis of A1ATD were adults. The peak age range was 50-64 years. Using 2 of the databases which included specific A1AT phenotypes, we found that many of these adults who undergo liver transplantation with A1ATD as the diagnosis are heterozygotes and have other potential causes of liver disease, most notably obesity and ethanol abuse. However, even when these cases are excluded and only ZZ and SZ phenotypes are considered, severe liver disease requiring transplantation is more than 2.5 times as likely in adults. The analysis also showed a markedly increased risk for males. In the pediatric group, almost all of the transplants are done in children less than 5 years of age. In conclusion, A1ATD causes progressive liver disease most commonly in adults with males in the highest risk category. In the pediatric group, children less than 5 years of age are highest in risk. These results suggest that A1ATD most commonly causes liver disease by mechanisms similar to age-dependent degenerative diseases and more rarely in children by powerful modifiers. Liver Transplantation 22 886-894 2016 AASLD.
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The model for end-stage liver disease (MELD) is considered to be a good predictor of disease status in patients with end-stage liver disease and has been used for organ distribution in liver transplantation. This article briefly describes the relationship between MELD, MELD-Na score and the mortality of patients waiting for liver transplantation, the intraoperative blood transfusion, the survival, complications, and re-transplantation after liver transplantation.
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End stage liver disease; Liver transplantation; MELD-Na score; Postoperative complications
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Nothing of him that doth fade, But doth suffer a sea-change Into something rich and strange. —William Shakespeare, The Tempest. Act i. Sc. 2. Liver transplantation has evolved over the past decade from an experimental, episodic technique, practiced in only a few centers, to a standard, accepted form of therapy for many different types of liver disease. Success rates for liver transplantation have continued to improve due to better surgical techniques, more efficacious and less toxic immunosuppressants, and, most importantly, better selection of candidates for liver transplantation. In the formative years of liver transplantation the procedure was offered mostly to patients with unresectable cancers or extreme liver failure. As experience has accumulated, clinicians have developed a better appreciation of the diagnoses for which liver transplantation is likely to be of benefit and for the optimal timing of treatment for many of these diseases. Recently, with the introduction of mathematical models such as the model for end-stage liver disease (MELD) and pediatric end-stage liver disease (PELD) scores that are accurate predictors of the risk of death for patients with chronic liver disease, liver transplant clinicians have come to understand that the need for liver transplantation can be defined for many types of liver disease. This concept represents a true “sea change” in clinical thinking regarding the referral, timing, and allocation of liver transplantation for waiting candidates. No longer are candidates “put in line to wait” for their transplant. The new risk models such as the MELD and PELD scores use objective patient-specific variables to define the risk of death for patients with chronic liver diseases within 3 months and thus define the need for transplant for a given individual at a given point in time that is objective and precise. However, there are many patients who do not have chronic progressively fatal liver disease for whom liver transplant offers beneficial treatment. For these indications, other end points such as the risk of disease progression and/or deterioration in the quality of life might be alternative measures on which to base new risk models. Even with a paucity of reliable natural history data for many of these conditions, one can begin to conceive of methods for evaluating indications for liver transplantation based on the risk model concept. The goal of the 2004 AASLD / ILTS Liver Transplant Course is to illuminate the indications for liver transplantation with the light of this evidence-based approach to liver disease and transplantation. My fellow course directors and I have assembled an international group of experts in the field of liver transplantation. These presenters have generously donated their time, for which we are thankful. Each will address an area of liver transplantation for which experience has evolved to a degree that allows for an evidence-based approach in evaluating the need for, and results obtainable with, liver transplantation. We have purposely selected areas in which controversy exists regarding the indication for liver transplantation in hopes of generating discussion and illuminating areas for future research. We hope that this syllabus is a helpful document summarizing the data presented during this course and that it will serve as a mental marker for the important exchange that we hope will occur among the attendees after the presentations. On behalf of my fellow course directors, Drs. Robert Merion and Michael Millis, I thank each of the contributors to this dynamic course, welcome all of you, and look forward to your active participation.
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The heart and liver are organs that are closely related in both health and disease. Patients who undergo liver transplantation may suffer from heart disease that is: (a) related to the original cause of the liver disease such as hemochromatosis, (b) related to the liver disease itself, or (c) related to other associated conditions. Furthermore, liver transplantation is one of the most cardiovascular stressful events that a patient with cirrhosis may undergo. After liver transplantation, the progression of pre-existing or the development of new-onset cardiac disease may occur. This article reviews the relationship between the heart and liver transplantation in the pre-transplant, intra-operative, and post-transplant periods.
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Background data: Liver transplantation is the best therapeutic option for patients with end- stage liver disease due to its excellent long term survival results. The demand for deceased donor liver transplantation vastly exceeds the supply. In the U.S. the Model for End Stage Liver Disease (MELD) score is now used for allocation in liver transplantation waiting lists, replacing the Child- Turcotte- Pugh (CTP) score. The MELD system is based on the risk of death without transplantation and was originally developed for survival estimation in patients after TIPS. The majority of the European countries still use the CTP score for liver organ allocation. However, there is a debate whether the MELD score is superior CTP to predict mortality in patients with cirrhosis on waiting list and after liver transplantation.
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