Introduction Severity of liver disease determines accurately the outcome of patients on liver transplant (LT) waiting list (WL). Comorbidities are known to affect post-LT outcomes but their effect on outcome of transplant assessment (TA) or WL mortality have not been fully explored in previous studies.
Aim To study the impact of comorbidities on TA, WL mortality and post LT survival.
Method Retrospective study of all patients assessed for LT at our centre between 1 January 2000 and 31 December 2007 (n=1484). Patients with acute liver failure (175), amyloid (43), those assessed for re-LT (149) and 24 with incomplete information were also excluded. Nine comorbidities (Charlson Comorbidity Index - CCI) were prospectively defined according to Volk et al (Liver Transplant 2007;13:1515–20). Kaplan–Meier analysis was performed to determine impact of comorbidity on outcome. Cox regression hazard analysis was used to determine predictors of outcome and presented as (OR, 95% CI, p value).
Results We analysed 1093 patients. Median age was 54 years (17–84), 67.5% were men (738). There were 192 (17.6%) patients with hepatocellular carcinoma (HCC). Patients with ≥1 comorbidity were 499 (46.6%) with most common comorbidities being diabetes (23.2%) and renal dysfunction (12.1%). Of 1093 assessed patients, 826 (75.6%) were listed. Patients with ≥1 comorbidity had significantly decreased LT free survival (log rank =33.586, p<0.001). Multivariate analysis showed CCI (1.79, 1.52 to 2.11, p<0.001), age (1.03, 1.00 to 1.05, p=0.035), Na (0.93, 0.89 to 0.97, p=0.001), MELD (1.10, 1.06 to 1.14, p<0.001) as being predictive. Of those listed for LT (826), 600 (72.6%) were transplanted, 161 (19.5%) died on WL and 65 (7.9%) were delisted. Listed patients with ≥1 comorbidity had significantly decreased LT free survival (log rank =9.045, p=0.003). Multivariate analysis showed CCI (1.79, 1.52 to 2.11, p<0.001), age (1.02, 1.01 to 1.03, p=0.006), pre-LT Hb level (0.87, 0.80 to 0.95, p=0.003), Na (0.96, 0.93 to 0.99, p=0.014) and MELD (1.14, 1.11 to 1.18, p<0.001) were predictors of listing outcome. Transplanted patients with ≥1 comorbidity had significantly decreased post LT survival (Log rank =7.645, p=0.006). Multivariate analysis showed that only CCI (1.36, 1.13 to 1.64, p=0.001) and HCC (1.74, CI 1.21–2.51, p=0.003) were independently associated with post-LT mortality. Similar post LT survival results seen when CCI was divided into 0, 1 and ≥2 comorbidities (Log rank =11.342, p=0.003).
Conclusion We demonstrate that comorbidities significantly impact on the outcome of patients with chronic liver disease at TA, on wait-list and post LT survival. Adding CCI to known liver prognostic models may improve their prediction ability.
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