Elsevier

Surgery

Volume 164, Issue 4, October 2018, Pages 694-704
Surgery

Early mortality after liver transplantation: Defining the course and the cause

https://doi.org/10.1016/j.surg.2018.04.039Get rights and content

Background

The objective of the current study was to define the incidence, as well as time course of mortality within the first year after liver transplantation.

Methods

Data on adult, first-time liver transplant recipients transplanted between February 2002 and June 2016 were obtained from the United Network for Organ Sharing.

Results

Among 64,977 who underwent liver transplantation, the incidence of 90-day and 1-year mortality was 5% and 10%, respectively. Although death associated with cardiovascular/cerebrovascular/pulmonary/hemorrhage was the most cause of death within the first 21 days (7-day: 53%), only 20% of liver transplantation patients died from these causes after 180 days. Infections were the most frequent cause of death during 30–180 days after liver transplantation. In contrast, after roughly 200 days from the time of liver transplantation, other causes of death were the most frequent cause of death. Although patients with autoimmune hepatitis, nonalcoholic steatohepatitis, and alcoholic cirrhosis had a similar risk of 1-year mortality, patients undergoing liver transplantation for viral hepatitis and hepatocellular carcinoma had an increased risk of 1-year mortality (viral: OR 1.56; hepatocellular carcinoma: OR 1.57; P < .001).

Conclusion

Roughly, 1 in 10 patients died within the first year after liver transplantation. The cause of death had a notable, time-specific variation over the first year after liver transplantation.

Introduction

In 2016, a total of 7,841 liver transplants (LT) were performed in the United States, with the majority (n = 7,496, 95.6%) being deceased donor transplants.1 Despite the trend for LT recipients in the United States being globally sicker, advances in operative techniques and medical management have resulted in incremental improvements in posttransplant survival.2, 3, 4 In fact, patients who underwent LT between 2008 and 2011 experienced a 5-year patient survival of 80%–85%.1 Survival after LT can vary among centers, with greater volume centers having better posttransplant patient survival.5, 6 In addition to center-specific characteristics, some authors have proposed certain predictive models to estimate risk of survival after LT.7, 8, 9 For example, the survival outcomes after LT transplantation score and the balance of risk score seek to assess survival 3 months posttransplant.7 In contrast, the risk models of the Scientific Registry of Transplant Recipients (SRTR) are largely used to assess post-LT outcomes at 1-year.10 In fact, after LT, the United Network for Organ Sharing (UNOS) uses 1-year mortality as the standard quality metric to assess program performance.11, 12, 13

Although 1-year mortality has become the metric to assess the performance of the LT program, understanding the timing and etiology-specific causes of death within the first year post-LT may be important. Despite this, most previous studies have not explicitly examined the causes of death after LT within the first year.14, 15, 16 In addition, reports on early post-LT death have only focused on perioperative risk factors, as well as on donor and recipient factors.17, 18 In contrast, there have been very few reports on the specific causes of death after LT within the first year. Rana et al10 reported an analysis of early death after adult LT. In this study, the authors noted that mortality was greatest within the first few days after LT, with the predominant cause of death being technical or operative.10 Other causes of early death after LT can be attributed to a variety of reasons, including operative complications, graft failure, cardiovascular disease, hemorrhage, infections, as well as to other factors. Timing of post-LT death within the first year may vary relative to a specific etiology. In turn, knowledge about the timing and specific causes of mortality within the first post-LT year may facilitate quality improvement.

Therefore, the objective of the current study was to define the mortality incidence, as well as time course of post-LT mortality within the first year after LT. In addition, we sought to characterize the specific causes of death and examine the cumulative incidence of cause-specific mortality relative to post-LT time of death within the first year after LT.

Section snippets

Population

A retrospective analysis was performed using the Standard Transplant Analysis and Research (STAR) files obtained from UNOS.19 The STAR file contained patient-level data collected by the Organ Procurement and Transplantation Network (OPTN). Data were collected at the time of LT, at 6-months post-LT, and then annually. Data on adult, first-time LT recipients transplanted between February 1, 2002, and June 30, 2016, were included to have 1-year outcomes for all patients. The September 2017 STAR

Results

Among the 64,977 patients who underwent LT, median (IQR) age of recipient patients was 55 years (49–61), and the median age of donors was 43 years (27–55) (Table 1). The majority of recipient and donor patients were male (recipient: n = 43,998, 67.7%; donor: n = 38,324, 59.5%) and white (recipient: n = 46,774, 72.0%; donor: n = 43,567, 67.0%). The most common indications for LT included viral hepatitis cirrhosis (n = 16,292, 25.1%), hepatocellular carcinoma (HCC) (n = 14,464, 22.3%), and

Discussion

LT is a life-saving treatment for end-stage liver disease (ESLD) and HCC. Throughout the past several decades, outcomes after LT have markedly improved. Specifically, with advances in treating viral hepatitis, as well as improvements in immune-suppression management, 5-year survival after LT now ranges 75%–85%.22, 23 In addition, short-term mortality has decreased because of better perioperative care, advancements in operative techniques, as well as changes in patient selection.24, 25, 26

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      Citation Excerpt :

      In the last 25 years, the survival rates have improved significantly, achieving rates of 96% and 71% at 1 and 10 years after LT, respectively [55]. Among 64,977 who underwent LT, the incidence of 90-day and 1-year mortality was 5% and 10%, respectively [56]. The mortality rate for LT of this study cohort at different time-points was perioperative in-hospital mortality (11.2%), 12-week mortality (13.8%), and at 1-year (15.8%) mortality.

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    Supported in part by Health Resources and Services Administration contract 234-2005-37011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.

    Presented at the 2018 annual meeting of the Central Surgical Association.

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