- Email: [email protected]
[37] OUTCOME OF PATIENTS TRANSPLANTED FOR PRIMARY SCLEROSING CHOLANGITIS - ANALYSIS OF THE EUROPEAN LIVER TRANSPLANT REGISTRY
Thur~xduy,I 2 April
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OUTCOME OF PATIENTS TRANSPLANTED FOR PRIMARY SCLEROSING CHOLANGITIS - ANALYSIS OF THE EUROPEAN LIVER TRANSPLANT REGISTRY C. Schramm’, M. Bubenheim2, J.G. O’Grady3, J. Buckels4, S . Pollard5, P. Neuhaus‘, N. Jamieson7, J. Klempnauer’, X. Rogiersg, V. Karam”, R. Adam”, A.W. Lohse’ . ‘I. Medical Deprtnzent, University Medical Center Hunt burg- Eppndorf,; Ham burg; Institute fbr Statistics iind Epidenziology, University Medical Center Hanzburb.-E~)~)endorf,~ Gernzany; ‘Liver Unit, Kings College Hospital, London; Departnzent of‘ Surgery, Queen Elizabeth Hospitul, Birminghum; ’Liuer Unit, St. James und Seucroft Uniuersih~Hospitul, Lee&, UK; ‘Depurtment of Surgery, Churite- Uniurrsituet~xklinikumz ~ Berlin, i Berlin, Germany; 7Depurtment of‘ Surgery, Addenbrookes Hospital, Cambridge, UK; ‘Department of Szirgeq Medizinische Hochschule Hannouer, Hunnouer; ’Department of Surgery, Uniuersity Medicul Center Humhurg-EpI)endo~f,’ Humburg, Germany; Centre H6puto-Biliuir.e, Hfipitul Puul B ~ O L I SPuris, S ~ , Frunw E-mail: [email protected]
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Background and Aims: The aim of OUT study was to compare the outcome of patients transplanted for primary sclerosing cholangitis (PSC) with patients transplanted for primary biliary cirrhosis (PBC) as well as alcoholic liver cirrhosis as a non immunological liver disease. Materials and Methods: Out of 10942 patients declared to the European liver transplant registry and transplanted between the years 1998 and 2004 for autoimmune liver disease or alcoholic cirrhosis, I2 I5 patients with PSC, 1365 with PBC and 5305 with alcoholic cirrhosis with a single diagnosis at transplantation were included. The time period was chosen in order to reflect the current standard of treatment. Statistical analysis was performed applying Kaplan-Meier estimates, log rank tests, Cox’ proportional hazard models and Holm’s procedure. The results are presented in terms of 5-year survival estimates and relative risks accompanied by their respective 95% C1. Results: 5-year patient survival after liver transplantation for PSC (0.84 (0.81-0.87) was similar to that for PBC (0.85 (0.82-0.87)) and significantly better than for patients transplanted for alcoholic cirrhosis (0.77 (0.75-0.78)). However, 5-year graft survival for PSC (0.75 (0.71-0.78)) tended to be worse than for PBC (0.81 (0.78-0.83)) and similar to that for alcoholic cirrhosis (0.73 (0.7 1-0.75)). Accordingly, the risk of retransplantation for patients with PSC was significantly higher than for PBC (RR 1.93 (1.45-2.57)) as well as for alcoholic cirrhosis. The reason for this may be a higher rate of vascular and biliary complications. In PSC, but not in PBC or alcoholic cirrhosis, recipient’s age had a significant impact on patient and graft survival. However, the risk of cardiovascular complications as cause of death was significantly lower in PSC as compared to PBC or alcoholic cirrhosis (RR 0.36 (0.14-0.9)). Within 5 years of transplantation for PSC, tumor development or recurrent disease did not seem to have a relevant impact on patient or graft survival. In PSC, the choice of immunosuppressive regimen did not significantly alter patient or graft survival. Conclusions: Liver transplantation for PSC demonstrates an excellent 5-year patient survival but the risk of retransplantation is higher as compared to PBC or alcoholic cirrhosis.
THE MELD IS SUPERIOR TO THE MADDREY TO PREDICT THE 3-MONTH MORTALITY IN ALCOHOLIC STEATOHEPATITIS (ASH): A STUDY IN 225 PATIENTS L. Spahr’, J. D ~u n o r t i er E. ~, Giostra’, T. Walter3, L. Rubbia-Brandt2, J.-Y. Scoazec3, A. Hadengue’. ‘Depurtment of Gustroenterology and Heputology, University Hospitul, Geneuu; Depurtment of Clinical Puthologj~,Uniuer~xih~ Hospitul, Geneuu, Switzerlund; ’D6purtement dex Muludies Digestiues, Hfipitul Edmund Herriot, Lyon, France E-mail: [email protected]
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Background and Aims: In ASH, hepatic encephalopathy (HE) or a Maddrey >32 indicate a benefit of steroids. This score, however, a) ignores a 15% mortality if 132, b) requires prothrombin time measuement (poorly standardized) and conversion into seconds (approximative), and c) was not reevaluated since 1978. MELD in ASH has been tested in heterogeneous studies where most patients were not biopsied nor steroid treated. We aimed to compare MELD, Maddrey, Child-Pugh scores, portal pressure, and biological tests obtained at baseline in patients with ASH as predictors of 3-month mortality. Methods: 225 patients (age 54 yrs, cirrhosis ~ 9 5 % with ) heavy alcohol use and biopsy-proven ASH (no virus or infection at admission) over 3.5 yrs. Variables (obtained at time of biopsy, median 4 days) were: MELD, Child-Pugh, Maddrey, presence of HE, bleed, renal failure, HVPG, leucocytes, AST, C-reactive protein (CRP), factor V All patients with Maddrey >32 or HE (= 72% of patients) received steroids. Results: Survival was 74%. Sixty patients died (median time 26 days [ 1-88]) from liver failure (n = 29), infection (n = 14), bleeding (n = 6) or other ( n = 1 I ) . At univariate analysis, Maddrey >32, Child-Pugh > l o , MELD >19, HE, GI bleed, creatinine >lo0 (all piO.OOl), age >50 (p 0.05), CRP >30 (p <0.02), and factor V 1 5 0 % (p 0.04) were associated with death at 3 months. Multivariate analysis, see Table. MELD AUROC was 0.846 (SE 0.027). A MELD > I 9 predicted death with a SendSpec of 88%/58%.
Age >50 yrs Creatinine >I00 bmol Presence of HE MELD >I9
OR [95%C1]
p-value
4 [1.45-6.251 4.6 [2.5-8.71 2.3 [1.254.25] 4 [1.8-9.25[
0.003 0.001 0.007 0.001
Conclusions: in this large group of patients with ASH, most in a severe form, MELD is supenor to the Maddrey to predict the 3-month mortality and may replace it to select patients who may benefit from steroids
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OUTCOME OF PATIENTS TRANSPLANTED FOR PRIMARY SCLEROSING CHOLANGITIS - ANALYSIS OF THE EUROPEAN LIVER TRANSPLANT REGISTRY C. Schramm’, M. Bubenheim2, J.G. O’Grady3, J. Buckels4, S . Pollard5, P. Neuhaus‘, N. Jamieson7, J. Klempnauer’, X. Rogiersg, V. Karam”, R. Adam”, A.W. Lohse’ . ‘I. Medical Deprtnzent, University Medical Center Hunt burg- Eppndorf,; Ham burg; Institute fbr Statistics iind Epidenziology, University Medical Center Hanzburb.-E~)~)endorf,~ Gernzany; ‘Liver Unit, Kings College Hospital, London; Departnzent of‘ Surgery, Queen Elizabeth Hospitul, Birminghum; ’Liuer Unit, St. James und Seucroft Uniuersih~Hospitul, Lee&, UK; ‘Depurtment of Surgery, Churite- Uniurrsituet~xklinikumz ~ Berlin, i Berlin, Germany; 7Depurtment of‘ Surgery, Addenbrookes Hospital, Cambridge, UK; ‘Department of Szirgeq Medizinische Hochschule Hannouer, Hunnouer; ’Department of Surgery, Uniuersity Medicul Center Humhurg-EpI)endo~f,’ Humburg, Germany; Centre H6puto-Biliuir.e, Hfipitul Puul B ~ O L I SPuris, S ~ , Frunw E-mail: [email protected]
’
,
Background and Aims: The aim of OUT study was to compare the outcome of patients transplanted for primary sclerosing cholangitis (PSC) with patients transplanted for primary biliary cirrhosis (PBC) as well as alcoholic liver cirrhosis as a non immunological liver disease. Materials and Methods: Out of 10942 patients declared to the European liver transplant registry and transplanted between the years 1998 and 2004 for autoimmune liver disease or alcoholic cirrhosis, I2 I5 patients with PSC, 1365 with PBC and 5305 with alcoholic cirrhosis with a single diagnosis at transplantation were included. The time period was chosen in order to reflect the current standard of treatment. Statistical analysis was performed applying Kaplan-Meier estimates, log rank tests, Cox’ proportional hazard models and Holm’s procedure. The results are presented in terms of 5-year survival estimates and relative risks accompanied by their respective 95% C1. Results: 5-year patient survival after liver transplantation for PSC (0.84 (0.81-0.87) was similar to that for PBC (0.85 (0.82-0.87)) and significantly better than for patients transplanted for alcoholic cirrhosis (0.77 (0.75-0.78)). However, 5-year graft survival for PSC (0.75 (0.71-0.78)) tended to be worse than for PBC (0.81 (0.78-0.83)) and similar to that for alcoholic cirrhosis (0.73 (0.7 1-0.75)). Accordingly, the risk of retransplantation for patients with PSC was significantly higher than for PBC (RR 1.93 (1.45-2.57)) as well as for alcoholic cirrhosis. The reason for this may be a higher rate of vascular and biliary complications. In PSC, but not in PBC or alcoholic cirrhosis, recipient’s age had a significant impact on patient and graft survival. However, the risk of cardiovascular complications as cause of death was significantly lower in PSC as compared to PBC or alcoholic cirrhosis (RR 0.36 (0.14-0.9)). Within 5 years of transplantation for PSC, tumor development or recurrent disease did not seem to have a relevant impact on patient or graft survival. In PSC, the choice of immunosuppressive regimen did not significantly alter patient or graft survival. Conclusions: Liver transplantation for PSC demonstrates an excellent 5-year patient survival but the risk of retransplantation is higher as compared to PBC or alcoholic cirrhosis.
THE MELD IS SUPERIOR TO THE MADDREY TO PREDICT THE 3-MONTH MORTALITY IN ALCOHOLIC STEATOHEPATITIS (ASH): A STUDY IN 225 PATIENTS L. Spahr’, J. D ~u n o r t i er E. ~, Giostra’, T. Walter3, L. Rubbia-Brandt2, J.-Y. Scoazec3, A. Hadengue’. ‘Depurtment of Gustroenterology and Heputology, University Hospitul, Geneuu; Depurtment of Clinical Puthologj~,Uniuer~xih~ Hospitul, Geneuu, Switzerlund; ’D6purtement dex Muludies Digestiues, Hfipitul Edmund Herriot, Lyon, France E-mail: [email protected]
’
Background and Aims: In ASH, hepatic encephalopathy (HE) or a Maddrey >32 indicate a benefit of steroids. This score, however, a) ignores a 15% mortality if 132, b) requires prothrombin time measuement (poorly standardized) and conversion into seconds (approximative), and c) was not reevaluated since 1978. MELD in ASH has been tested in heterogeneous studies where most patients were not biopsied nor steroid treated. We aimed to compare MELD, Maddrey, Child-Pugh scores, portal pressure, and biological tests obtained at baseline in patients with ASH as predictors of 3-month mortality. Methods: 225 patients (age 54 yrs, cirrhosis ~ 9 5 % with ) heavy alcohol use and biopsy-proven ASH (no virus or infection at admission) over 3.5 yrs. Variables (obtained at time of biopsy, median 4 days) were: MELD, Child-Pugh, Maddrey, presence of HE, bleed, renal failure, HVPG, leucocytes, AST, C-reactive protein (CRP), factor V All patients with Maddrey >32 or HE (= 72% of patients) received steroids. Results: Survival was 74%. Sixty patients died (median time 26 days [ 1-88]) from liver failure (n = 29), infection (n = 14), bleeding (n = 6) or other ( n = 1 I ) . At univariate analysis, Maddrey >32, Child-Pugh > l o , MELD >19, HE, GI bleed, creatinine >lo0 (all piO.OOl), age >50 (p 0.05), CRP >30 (p <0.02), and factor V 1 5 0 % (p 0.04) were associated with death at 3 months. Multivariate analysis, see Table. MELD AUROC was 0.846 (SE 0.027). A MELD > I 9 predicted death with a SendSpec of 88%/58%.
Age >50 yrs Creatinine >I00 bmol Presence of HE MELD >I9
OR [95%C1]
p-value
4 [1.45-6.251 4.6 [2.5-8.71 2.3 [1.254.25] 4 [1.8-9.25[
0.003 0.001 0.007 0.001
Conclusions: in this large group of patients with ASH, most in a severe form, MELD is supenor to the Maddrey to predict the 3-month mortality and may replace it to select patients who may benefit from steroids