Orthopedic liver transplantation in high-risk patients

Background. One of the most controversial area in patients selection and donor allocation in the high-risk patient. Risk factors for mortality and major infectious morbidity were prospectively analyzed in consecutive United States veterans undergoing the liver transplantation under primary tacrolimus-based immunosuppression. Methods. Twenty-eight pro-liver transplant, operative and posttransplant risk factors were examined univariately and multivariately in 140 consecutive liver transplant in 1130 veterans (98% male); mean age 47.3 years) Results. Eighty-two percent of the patients had postnecrotic cirrhosis due to viral hepatitis or ethanol (20% ethanol alone), and only 12% had cholestatic liver disease. Ninety-eight percent of the patients were hospitalized at the time of transplantation (66% Unites Network for Network for Organ Sharing [UNOS] 2, 32% UNOS 1). Major bacterial infection, posttransplant dialysis, additional immunosuppression, readmission to intensive care unit (p=0.0001 for all), major fungal infection, posttransplant abdominal surgery, posttransplant intensive care unit stay length of stay (p<0.005 for all), donor age, pretransplant dialysis, and creatinine (P<0.05 for all) were significantly associated with morality by univariate analysis. Underlying liver disease cytomegalovirus infection and disease, portal vein thrombosis, UNOS status, Childs-Pugh score, patient age, pretransplant bilirubin, bilirubin time, and operative blood loss were not significant predictors of mortality. Patients with hepatitis C (HCV) and recurrent HCV a trend toward higher mortality (P=0.18). By multivariate analysis, donor age, any major infection, additional immunosuppresion, post-transplant dialysis, and subsequent transplantation were significant independent predictors of mortality (P<0.05). Major infectious morbidity was associated with HCV recurrence (P=0.003), posttransplant dialysis (P=0.0001), pretransplant creatine, donor age, median blood loss, intensive care unit length of stay, additional immunosuppression, and biopsy-proven rejection (P<0.05 for all). By multivariate analysis, intensive care unit length of stay and additional immunosuppression were significant independent predictors of infectious morbidity (P<0.03). HCV recurence was of borderline significance (P=0.07). Conclusions. Biologic and physiologic parameters appear to be more powerful predictors of mortality and morbidity after liver transplantation. Both donor and recipient variables need to be considered for early and late outcome analysis and risk assessment modeling.