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P71 A model to improve performance of current category 9 UK listing criteria: early liver graft dysfunction. A single centre cohort
  1. M A B Al-Freah,
  2. E Dionigi,
  3. M J W McPhail,
  4. M Foxton,
  5. G Auzinger,
  6. M Rela,
  7. N D Heaton,
  8. J G O'Grady,
  9. M A Heneghan,
  10. W Bernal,
  11. J A Wendon
  1. Institute of Liver Studies, King's College Hospital, London, UK

Abstract

Introduction Current super urgent criteria for listing for early liver graft dysfunction (ELGD) in the UK (category 9, C9C) is defined as fulfilling 2 out of 4 of the following criteria within 7 days post liver transplant (LT): AST >10 000IU/l, INR >3, Lactate >3 mmol/l and absence of bile production. We demonstrated that these criteria have critically low sensitivity in predicting early post LT death or need for re-LT (Al-Freah, et al. Hepatology 2009;50 Suppl 4:A148).

Aim To develop an improved predictive model for early re-LT or death using early post-LT clinical parameters.

Method Retrospective study of all patients transplanted at our centre 1 January 2000 to 31 December 2008. Daily clinical and laboratory parameters for the first 7 days post LT were reviewed. These included AST, bilirubin, INR, lactate, vasopressor requirement and/or haemofiltration.

Results Over the study period, 1286 patients underwent first LT at our centre. Patients excluded (28) because of re-LT for hepatic artery thrombosis (22), died on table (5) and one re-LT because of donor cancer. We analysed data on 1258 patients (median age 51 (16–74) years (16–74), 60% male). The most common aetiology was viral hepatitis in 303 patients (24%) and alcohol related liver disease in 227 patients (18%); 181 patients (14.4%) with hepatocellular carcinoma. Median MELD score was 16 (6–40). Death or re-LT rate at 3 months was 9.9% (124). Only 27 (2.1%) fulfilled C9C at 3 months: 17 (63%) of those died or had re-LT within 3 months (p<0.001). C9C had sensitivity of 14% (9.8–17%), specificity 99% (98–99%), positive likelihood ratio (LR+) 15.533 (7.41–32.73) and negative likelihood ration (LR−) 0.87 (0.83–0.91). Abstract P71 table 1 shows the univariate and multivariate analyses of predictors of 3 months liver-related death or re-LT using Cox regression hazard method. Accordingly, we generated a model comprises any 1 of the following 5 to predict ELGD and death or re-LT: vasopressor requirement at day D7, D1 lactate >3 mmol/l, D7 AST >500 IU/l and D7 bilirubin >100 μmol/l. Those scored 1, 2, 3, 4 or 5 points had OR of risk of death/re-LT within 3 months of 1.26 (0.897–1.766, p=0.184), 1.345 (0.8817–2.051, p=0.171), 2.811 (1.669–4.732, p=0.0001), 15.561 (7.425–32.611, p<0.0001) and 36.509 (13.188–101.074, p<0.0001), respectively. 85 of 124 patients who had a 3 month liver related outcome met this criterion compared to 16 who met C9C. This gave sensitivity 68% (58–77%), specificity 67% (64–70%), LR+ 2.08 (1.77–2.45) and LR− 0.48 (0.36–0.63).

Abstract P71 Table 1

Cox regression hazard analysis of predictors of 3 months liver related deaths or re-LT

Conclusion The new model is simple to use and significantly improved the sensitivity of detection of severe ELGD. Validation in another cohort of LT patients is warranted.

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