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Adult liver transplant programs have heretofore been hesitant to perform liver retransplantation in adult patients who underwent primary liver transplantation as a child (P_A). Areas of concern include: (a) potential disruption in care when transferring from a pediatric to an adult transplant center; (b) generally inferior outcomes of retransplantation; (c) reputation of young adults for non-adherence to post-transplant regimen; and (d) potential higher work effort for equivalent outcomes. To examine these concerns, we reviewed data on all US liver adult retransplants from 10/01/1987 to 9/30/2017. We propensity matched the P_A patients to patients who received both primary and retransplantation as adults (A_A), with ≥550 days between transplants. A mixed Cox proportional hazards model with program size and time period of transplantation as random variables revealed that retransplantation of P_A patients produced no significantly different graft survival or patient survival rates than retransplantation of the matched A_A patients. Therefore, inferior rates of liver retransplantation in these patients and concerns about continuity of care in changing transplant programs are not as believed in the wider liver transplant community. In conclusion, liver transplant centers should be optimistic about retransplanting adults who received their primary transplants as children., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

In this era of organ scarcity, living donor liver transplantation (LDLT) is an alternative to using deceased donors, and in Western countries, it is more often used for recipients with low Model for End-Stage Liver Disease (MELD) scores. We sought to compare the patient survival and graft survival between recipients of liver transplantation from living donors and donation after circulatory death (DCD) donors in patients with low MELD scores. This is a retrospective cohort analysis of adult liver transplant recipients with a laboratory MELD of ≤20 who underwent transplantation between January 1, 2003 and March 31, 2016. Recipients were categorized by donor graft type (DCD or LDLT), and recipient and donor characteristics were compared. Ten-year patient and graft survival curves were calculated using Kaplan-Meier analyses, and a mixed-effects model was performed to determine the contributions of recipient, donor, and center variables on patient and graft survival. There were 36,705 liver transplants performed: 32,255 (87.9%) from DBD donors, 2166 (5.9%) from DCD donors, and 2284 (6.2%) from living donors. In the mixed-effects model, DCD status was associated with a higher risk of graft failure (relative risk [RR], 1.27; 95% confidence interval [CI], 1.16-1.38) but not worse patient survival (RR, 1.27; 95% CI, 0.96-1.67). Lower DCD center experience was associated with a 1.21 higher risk of patient death (95% CI, 1.17-1.25) and a 1.13 higher risk of graft failure (95% CI, 1.12-1.15). LDLT center experience was also predictive of patient survival (RR, 1.03; 95% CI, 1.02-1.03) and graft failure (RR, 1.05; 95% CI, 1.05-1.06). In conclusion, for liver transplant recipients with low laboratory MELD, LDLT offers better graft survival and a tendency to better patient survival than DCD donors., (Copyright © 2018 by the American Association for the Study of Liver Diseases.)

Objectives: The use of induction therapy in liver transplant is debatable. We aimed to compare clinical outcomes of different induction protocols in liver transplant recipients., Materials and Methods: This was a retrospective cohort analyses using the University of Washington Transplant Database from January 2005 to May 2012 for adult (≥ 18 y old) primary liver transplant patients. All patients received induction therapy. Maintenance immunosuppressive agents were tacrolimus or tacrolimus-mycophenolate mofetil. Primary endpoints were acute cellular rejection, patient survival, and graft survival. In patients with chronic hepatitis C, the degree of histologic inflammation or fibrosis at 1 year was assessed. Cox proportional hazards models were constructed to evaluate variables associated with both patient and graft survival., Results: We identified 595 patients: 322 patients received rabbit antithymocyte globulin and 273 received interleukin 2 receptor blocker. Acute cellular rejection was higher in patients who received interleukin 2 receptor blocker than in patients who received rabbit antithymocyte globulin (27% vs 18%; P < .03). Both patient survival at 1 year (95% vs 90%), 3 years (92% vs 87%), and 5 years (86% vs 80%) and graft survival at 1 year (93% vs 88%), 3 years (90% vs 86%), and 5 years (83% vs 78%) were superior with rabbit antithymocyte globulin than with the interleukin 2 receptor blocker (P < .002). In patients with hepatitis C virus, type of induction therapy did not have any effect on the timing of hepatitis C virus recurrence. At 1 year after transplant, 33.3% in the rabbit antithymocyte globulin group had grade 3/4 inflammation and 10.2% had stage 3/4 fibrosis, compared with 16.8% and 4.8% in the interleukin 2 receptor blocker group (P ≤ .002 and not significant). Female recipient, Model for End-Stage Liver Disease score, hepatocellular carcinoma, and high preoperative serum creatinine levels were associated with less favorable patient and graft survival., Conclusions: Rabbit antithymocyte globulin is associated with lower rejection rate and improved patient and graft survival in liver transplant. Type of therapy affects the degree of histologic hepatitis C virus recurrence.

Background: In orthotopic liver transplantation (OLT) size-mismatch may cause adverse outcomes. We previously reported on a method to predict donor-recipient size-mismatch using the body surface area index (BSAi). In this study, we hypothesized that graft survival of size-mismatch transplantation deteriorates with higher model for end-stage liver disease (MELD) score at transplantation., Methods: We evaluated non-parametrically the association of BSAi and MELD with 1-year graft survival with a generalized additive model. For derivation, transplantations performed between 2005 and 2010 were used. The associations were then validated by comparing Kaplan-Meier estimates between patient groups stratified according to estimated risk, using transplantations from 2011-2013., Results: A total of 30,870 OLT were included in the study with 16,466 in the validation group. The derivation model revealed that graft survival significantly decreased with higher or lower BSAi, and with higher MELD (P < 0.0001). Validation confirmed the correlation of observed graft survival with estimated risk categories., Conclusions: We found that there is an interactive effect between MELD score and size-mismatch. Also high MELD recipient has a narrower safety margin for size-mismatched graft. The risk calculated from our nonparametric model with MELD and BSAi well predicts outcome in liver transplantation., (© 2016 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background: Significant geographic disparities exist in access to liver transplantation and consequently the current liver allocation system is being challenged. We sought to describe our unique experience with using organs with long cold ischemia times from the largest donation service area., Material and Methods: From 2009-2014 we performed 350 liver transplants. 167 (48%) had a cold ischemia time <8 hours, 134 (38%) between 8 and 12 hours, and 49 (14%) greater than 12 hours., Results: Early allograft dysfunction was observed more commonly with increasing cold ischemia times. 53% of the recipients in the >12 h group had early allograft dysfunction compared to 28% in the 8-12 h group, and 18% in the <8 h group (P<0.001). We found no correlation between early allograft dysfunction and allograft or patient survival. One-year liver allograft survival was 92%, 94%, 87%, three-year graft survival was 82%, 89%, and 87%, and five-year graft survival was 82%, 89%, and 79% in the <8 h, 8-12 h, and >12 h cold ischemia time groups, respectively. One-year patient survival was 95%, 94%, and 92% and five-year patient survival was 90%, 89%, and 83% in the <8 h, 8-12 h, and >12 h cold ischemia time groups, respectively. Both unadjusted and multivariate Cox regression analyses indicated no statistically significant associations between cold ischemia time and graft or patient survival., Conclusions: In conclusion, the prolonged cold ischemia time led to early allograft dysfunction but did not have a deleterious association with graft or patient survival.

Background: We hypothesized that operative variables might predict survival following liver transplantation., Methods: We examined perioperative variables from 469 liver transplants carried out at the University of Washington during 2003-2006. Logistic regression determined the variables' contributions to survival at 30, 90 and 365 days., Results: Portal vein blood flow (>1 l/min) was significant to patient survival at 30, 90 and 365 days. Complete reperfusion was only a significant predictor of survival at 30 days. This provided model receiver operating characteristic (ROC) area under the curve (AUC) statistics of 0.93 and 0.87 for 30 and 90 days, respectively. At 365 days, hepatic artery blood flow (>250 ml/min) combined with portal vein blood flow was significantly predictive of survival, with an AUC of 0.74. A subset analysis of 110 transplants demonstrated improved 1-year survival with more aggressive vascular revisions., Discussion: Portal vein blood flow is a significant predictor of survival after liver transplantation. Initially, the liver's survival is based on portal vein blood flow; however, subsequent biliary problems and patient demise result from both poor portal vein and inadequate hepatic artery blood flow.

The use of donation after cardiac death (DCD) donor hepatic allografts is becoming more widespread; however, there have been published reports of increased graft failure from specific complications associated with this type of allograft. The complication of ischemic cholangiopathy (IC) has been reported to occur more frequently after the use of DCD hepatic allografts. We report the results of 52 liver transplants from DCD donors and the factors that influenced the development of IC. We conducted a retrospective review of all DCD and donation after brain death (DBD) donor liver recipients from September 2003 through December 2006 at a single institution. Survival and complication rates were compared between the 2 groups. The Cox proportional hazards model was then used to identify recipient and donor factors that predict the development of IC in the DCD group. There was no difference in 1-year patient or graft survival rates between the 2 groups. There was no incidence of primary nonfunction from the DCD allografts. Hepatic artery complications and anastomotic bile duct complications were comparable in the 2 groups. There was, however, an increased risk for the development of IC in the DCD group (13.7% versus 1%, P = 0.001). Donor weight >100 kg and total ischemia times > or =9 hours, in donors older than 50 years of age, predicted the development of IC in the DCD group. In conclusion, there is a higher incidence of IC in recipients receiving DCD donor livers; however, patient and graft outcomes with DCD donors remain comparable to those with DBD donors. Careful donor selection may improve utilization of these grafts.

Objective: There is an unmet need for optimizing hepatic allograft allocation from nondirected living liver donors (ND-LLD). Materials and method: Using OPTN living donor liver transplant (LDLT) data (1/1/ 2000-12/31/2019), we identified 6328 LDLTs (4621 right, 644 left, 1063 left-lateral grafts). Random forest survival models were constructed to predict 10-year graft survival for each of the 3 graft types. Results: Donor-to-recipient body surface area ratio was an important predictor in all 3 models. Other predictors in all 3 models were: malignant diagnosis, medical location at LDLT (inpatient/ICU), and moderate ascites. Biliary atresia was important in left and left-lateral graft models. Re-transplant was important in right graft models. C-index for 10-year graft survival predictions for the 3 models were: 0.70 (left-lateral); 0.63 (left); 0.61 (right). Similar C-indices were found for 1-, 3-, and 5-year graft survivals. Comparison of model predictions to actual 10-year graft survivals demonstrated that the predicted upper quartile survival group in each model had significantly better actual 10-year graft survival compared to the lower quartiles (p<0.005). Conclusion: When applied in clinical context, our models assist with the identification and stratification of potential recipients for hepatic grafts from ND-LLD based on predicted graft survivals, while accounting for complex donor-recipient interactions. These analyses highlight the unmet need for granular data collection and machine learning modeling to identify potential recipients who have the best predicted transplant outcomes with ND-LLD grafts. [ABSTRACT FROM AUTHOR]