Survival after liver transplantation in the United Kingdom and Ireland compared with the United States

Muhammad F Dawwas ^1*, Alexander E Gimson ¹, James D Lewsey ², Lynn P Copley ³ and Jan HP van der Meulen ³

¹ Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, United Kingdom
² London School of Hygiene and Tropical Medicine, United Kingdom
³ The Royal College of Surgeons of England, United Kingdom

^* To whom correspondence should be addressed. E-mail: drdawwas{at}gmail.com.

Accepted 28 February 2007

Abstract

Background and Aim: Surgical mortality in the US is widely perceived to be superior to that in the UK. However, previous comparisons of surgical outcome in the two countries have often failed to take sufficient account of case-mix or examine long-term outcome. The standardised nature of liver transplantation practice makes it uniquely placed for undertaking reliable international comparisons of surgical outcome. The objective of this study is to undertake a risk-adjusted disease-specific comparison of both short- and long-term survival of liver transplant recipients in the UK and Ireland with that in the US.

Design, setting and participants: Multi-centre cohort study using two high quality national databases including all adults who underwent a first single organ liver transplant in the UK and Ireland (n=5,925) and the US (n=41,866) between March 1994 and March 2005.

Main outcome measures: Post-transplant mortality during the first 90 days, 90 days-1 year and beyond the first year, adjusted for donor and recipient characteristics.

Results: Risk-adjusted mortality in the UK and Ireland was generally higher than in the US during the first 90 days (hazard ratio 1.17 95%CI 1.07-1.29), both for patients transplanted for acute liver failure (hazard ratio 1.27 95%CI 1.01-1.60) as well as those transplanted for chronic liver disease (hazard ratio 1.18 95% CI 1.07- 1.31). Between 90 days and 1 year post-transplantation, no statistically significant differences in overall risk- adjusted mortality were noted between the two cohorts. Survivors of the first post-transplant year in the UK and Ireland had lower overall risk-adjusted mortality than those transplanted in the US (hazard ratio 0.88 95% CI 0.81- 0.96). This difference was observed among patients transplanted for chronic liver disease (hazard ratio 0.88 95%CI 0.81-0.96) but not those transplanted for acute liver failure (hazard ratio 1.02 95%CI 0.70- 1.50).

Conclusions: Whilst risk adjusted mortality is higher in the UK and Ireland during the first 90 days following liver transplantation, it is higher in the US among those liver transplant recipients who survived the first post- transplant year. Our results are consistent with the notion that the US has superior acute peri-operative care whereas the UK appears to provide better quality chronic care following liver transplantation surgery.

Keywords: Great Britain, liver transplantation, outcome, quality of healthcare, United States

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