- Email: [email protected]
464 CHRONIC RENAL DYSFUNCTION AFTER LIVER TRANSPLANTATION: RISK FACTORS AND A NEW PREDICTIVE SCORE
01b: LIVER TRANSPLANTATION/SURGERY/ACUTE LIVER FAILURE − b) CLINICAL Pegboard), executive function (Hooper) and memory (Auditory Verbal Learning). Results: 1. Short-term post-LTx: The VV (cm3) increased by 8%. Fourteen patients exhibited FWML that decreased the volume by 20%, which can be explained by reversible brain edema in this areas. Neuropsychological tests improved indicating reversal of minimal hepatic encephalopathy. 2. Long-term post-LTx: The VV increased by 60% and the volume of FWML increased by 25%. Neuropsychological tests remained stable, except for memory that showed deterioration. Changes in VV or FWML were not associated with prior HE. Among patients with larger changes in FWML (>15%) pharmacological treatment for arterial hypertension was more common (88% vs. 33%, p = 0.05) and creatinine tended to be higher (1.37±0.21 vs. 1.19±0.15 mg/dl, p = 0.06). Conclusion: Following LTx patients develop a decrease in brain volume despite a successful outcome of liver function. The initial decrease probably reflects disappearance of brain edema related to HE. The decrease at long-term is part of a degenerative process in part caused by small-vessel cerebrovascular disease. Adequate control of vascular risk factors appears critical to prevent neurological deterioration following LTx.
464 CHRONIC RENAL DYSFUNCTION AFTER LIVER TRANSPLANTATION: RISK FACTORS AND A NEW PREDICTIVE SCORE F. Gentili, M. Giusto, I. Loria, S. Ginanni Corradini, A. Molinaro, A.F. Attili, G. Mennini, M. Rossi, M. Merli. Centro Trapianti Policlinico Umberto I Universit`a di Roma La Sapienza, Roma, Italy E-mail: [email protected] Background: Chronic renal dysfunction (CRD) is a frequent complication after liver transplantation (LT). The origin of CRD is probably multifactorial. We prospectively analyzed the incidence of CRD after LT and the potential risk factors. Patients and Methods: Two-hundred-two patients undergoing LT were considered. Patients were excluded if: survival or follow up <3 months; multiple organ transplantation; no compliance to periodic follow-up; diagnosis of organic renal failure. Immunosuppressive therapy immediately after transplantation was always based on steroids, calcineurin inhibitors and azathioprine or Mycophenolate mophetyl unless contraindicated. The diagnosis of CRD was based on serum creatinine 1.5 mg/dl in two subsequent controls. Creatinine clearance was also calculated according to Modification of Diet in Renal Disease (MDRD), simplified MDRD (sMDRD) and Cockcroft-Gault formula (CG), every three-six months. Statistical analysis: The incidence of CRD was described by Kaplan– Meier plots. Factors associated with CRD were analysed by univariate analysis- Log-Rank test. Factors selected by this analysis were also included in a multivariate analysis (Cox regression model) to assess their role as independent risk factors. Result: One-hundred-fifty-two patients (120 males, mean age 54±9 years, follow up 48±29 months) were included. Origin of liver disease was hepatitis C (43%), hepatitis B(21%), alcohol(16%). Cumulative incidence of CRD was 18.3%(95% CI: 13−26) at one year and 35.2%(95% CI: 27.0−45.0) at five years. One months after LT the accuracy of formulas used to estimate creatinine clearance (MDRD, sMDRD, CG) to predict the diagnosis of CDR was calculated using ROC curve, and resulted respectively 0.72(95% CI: 0.61−0.79), 0.71(95% CI: 0.56−0.74), 0.59(95% CI: 0.47−0.69). Factors associated with the development of CRD were diabetes (p = 0.0005) and renal impairment before LT (p = 0.001), age >60 yrs (p = 0.004) at LT, diabetes (p = 0.001) and “de novo” arterial hypertension (p = 0.02), episodes of organ rejection (p = 0.05), or biliary complications (p = 0.002). Independent predictors of CRD were renal impairment before LT, diabetes and a MDRD creatinine clearance >60 ml/min at one months. A score including these parameters was elaborated for the prediction of CRD (AUC 0.76(CI 95%:0.69−0.82)). Conclusions: Diabetic patients with functional renal failure before LT and reduced MDRD clearance 1 month after LT have a high probability to develop CRD.
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465 CAN WE SAFELY USE DONOR LIVERS WITH STEATOSIS IN HCV-POSITIVE RECIPIENTS? G. Germani1 , M. Loreno1 , F.P. Russo1 , E. Perissinotto2 , M. Senzolo1 , A. Masier1 , E. De Martin1 , M. Gambato1 , C. Ferronato1 , U. Cillo3 , M. Rugge4,5 , P. Burra1 . 1 Department of Surgical and Gastroenterological Sciences, Gastroenterology, 2 Department of Environmental Medicine and Public Health, 3 Department of Surgical and Gastroenterological Sciences, Surgical Unit, 4 Veneto Institute of Oncology (IOV) − Pathology Unit, 5 Department of Medical Diagnostic Sciences and Special Therapies − Pathology Unit II, University of Padova, Padova, Italy E-mail: [email protected] Background: Whether donor graft steatosis affects liver function and influences survival after liver transplantation (LT) are issues still open to debate. Aim: To assess the impact of donor graft steatosis on long-term liver histology after LT. Methods: 116 consecutive LTs were performed in 56 HCV+ and 60 HCV− patients who had protocol liver biopsies at 6, 12, 24 and 36 months after LT. Liver biopsies were obtained from all grafts. Results: No steatosis was seen in 50.9% of the biopsies taken before implantation, whereas steatosis was mild in 39.6% and moderate/severe in 9.5%. During the 36-month follow-up, 373 protocol biopsies were obtained. In the 56 HCV+ recipients, fibrosis stage 3−4 was seen in 24.4% of 45 biopsies at 36 months after LT. The progression of fibrosis stage 3−4 after LT was significantly worse in HCV+ than HCV− recipients (p = 0.03 at 6 months, p = 0.003 at 12 months, p = 0.02 at 24 months and p = 0.001 at 36 months). No difference in 36-month survival after LT was seen, regardless of whatever the aetiology of the patient’s liver disease was HCV+ or HCV− (80.3% vs. 75%) and whether the steatosis in the graft was absent, mild or moderate/severe (79.7% vs. 73.9% vs. 81.1%). Among HCV+ patients no difference in three-year survival rate was seen between who received grafts with steatosis from <50 year or 50-year-old donor. Recipient 50 years old (OR 3.44, 95% CI 1.19−10), a poor liver function soon after LT (OR 5.93, 95% CI 1.50−23.5) and diabetes mellitus pre-LT (OR 4, 95% CI 1.47−10.71) were independent risk factors of death 36 months after LT. HCV aetiology (OR 6.34, 95% CI 2.2−13.5) was the only independent factor associated with fibrosis progression. Neither the donor’s age nor donor graft steatosis correlated with fibrosis progression after LT. Conclusions: Nearly 1/4 of HCV+ recipients have pre-cirrhosis/cirrhosis 3 years after LT. Older recipient, a poor liver function soon after LT and pre-LT diabetes mellitus are associated with poor outcome at 3-year postLT. Steatotic grafts do not seem to exacerbate the progression of fibrosis in HCV+ recipients, nor seem to negatively affect 3-year patient survival. 466 NATREMIA AND CHILD-TURCOTTE-PUGH (CTP) SCORE MAY IMPROVE THE SELECTION OF CANDIDATES FOR LIVER TRANSPLANTATION (LT) WITH LOW MODEL FOR END-STAGE LIVER DISEASE SCORE (MELD) S. Gitto1 , M. Biselli1 , A. Gramenzi1 , G. Vitale1 , S. Lorenzini1 , R. Di Donato1 , L. Brodosi1 , M.C. Morelli2 , G.L. Grazi2 , A.D. Pinna2 , M. Bernardi1 , P. Andreone1 , Bologna Liver Transplantation Group (BLTG). 1 Department of Clinical Medicine, 2 Department of General Surgery and Organ Transplantation, University of Bologna, Bologna, Italy E-mail: [email protected] Background and Aims: It is well known that the survival benefit of LT depends on candidate disease severity, as measured by MELD that is widely used for the organ allocation. It has been suggested that LT for patients with low MELD should be reconsidered. The aim of this study was to evaluate whether other factors were able to better select the low MELD candidates. Methods: The waiting list mortality of 452 cirrhotic patients consecutively listed for LT between January 2003 and October 2008 at the Bologna
464 CHRONIC RENAL DYSFUNCTION AFTER LIVER TRANSPLANTATION: RISK FACTORS AND A NEW PREDICTIVE SCORE F. Gentili, M. Giusto, I. Loria, S. Ginanni Corradini, A. Molinaro, A.F. Attili, G. Mennini, M. Rossi, M. Merli. Centro Trapianti Policlinico Umberto I Universit`a di Roma La Sapienza, Roma, Italy E-mail: [email protected] Background: Chronic renal dysfunction (CRD) is a frequent complication after liver transplantation (LT). The origin of CRD is probably multifactorial. We prospectively analyzed the incidence of CRD after LT and the potential risk factors. Patients and Methods: Two-hundred-two patients undergoing LT were considered. Patients were excluded if: survival or follow up <3 months; multiple organ transplantation; no compliance to periodic follow-up; diagnosis of organic renal failure. Immunosuppressive therapy immediately after transplantation was always based on steroids, calcineurin inhibitors and azathioprine or Mycophenolate mophetyl unless contraindicated. The diagnosis of CRD was based on serum creatinine 1.5 mg/dl in two subsequent controls. Creatinine clearance was also calculated according to Modification of Diet in Renal Disease (MDRD), simplified MDRD (sMDRD) and Cockcroft-Gault formula (CG), every three-six months. Statistical analysis: The incidence of CRD was described by Kaplan– Meier plots. Factors associated with CRD were analysed by univariate analysis- Log-Rank test. Factors selected by this analysis were also included in a multivariate analysis (Cox regression model) to assess their role as independent risk factors. Result: One-hundred-fifty-two patients (120 males, mean age 54±9 years, follow up 48±29 months) were included. Origin of liver disease was hepatitis C (43%), hepatitis B(21%), alcohol(16%). Cumulative incidence of CRD was 18.3%(95% CI: 13−26) at one year and 35.2%(95% CI: 27.0−45.0) at five years. One months after LT the accuracy of formulas used to estimate creatinine clearance (MDRD, sMDRD, CG) to predict the diagnosis of CDR was calculated using ROC curve, and resulted respectively 0.72(95% CI: 0.61−0.79), 0.71(95% CI: 0.56−0.74), 0.59(95% CI: 0.47−0.69). Factors associated with the development of CRD were diabetes (p = 0.0005) and renal impairment before LT (p = 0.001), age >60 yrs (p = 0.004) at LT, diabetes (p = 0.001) and “de novo” arterial hypertension (p = 0.02), episodes of organ rejection (p = 0.05), or biliary complications (p = 0.002). Independent predictors of CRD were renal impairment before LT, diabetes and a MDRD creatinine clearance >60 ml/min at one months. A score including these parameters was elaborated for the prediction of CRD (AUC 0.76(CI 95%:0.69−0.82)). Conclusions: Diabetic patients with functional renal failure before LT and reduced MDRD clearance 1 month after LT have a high probability to develop CRD.
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465 CAN WE SAFELY USE DONOR LIVERS WITH STEATOSIS IN HCV-POSITIVE RECIPIENTS? G. Germani1 , M. Loreno1 , F.P. Russo1 , E. Perissinotto2 , M. Senzolo1 , A. Masier1 , E. De Martin1 , M. Gambato1 , C. Ferronato1 , U. Cillo3 , M. Rugge4,5 , P. Burra1 . 1 Department of Surgical and Gastroenterological Sciences, Gastroenterology, 2 Department of Environmental Medicine and Public Health, 3 Department of Surgical and Gastroenterological Sciences, Surgical Unit, 4 Veneto Institute of Oncology (IOV) − Pathology Unit, 5 Department of Medical Diagnostic Sciences and Special Therapies − Pathology Unit II, University of Padova, Padova, Italy E-mail: [email protected] Background: Whether donor graft steatosis affects liver function and influences survival after liver transplantation (LT) are issues still open to debate. Aim: To assess the impact of donor graft steatosis on long-term liver histology after LT. Methods: 116 consecutive LTs were performed in 56 HCV+ and 60 HCV− patients who had protocol liver biopsies at 6, 12, 24 and 36 months after LT. Liver biopsies were obtained from all grafts. Results: No steatosis was seen in 50.9% of the biopsies taken before implantation, whereas steatosis was mild in 39.6% and moderate/severe in 9.5%. During the 36-month follow-up, 373 protocol biopsies were obtained. In the 56 HCV+ recipients, fibrosis stage 3−4 was seen in 24.4% of 45 biopsies at 36 months after LT. The progression of fibrosis stage 3−4 after LT was significantly worse in HCV+ than HCV− recipients (p = 0.03 at 6 months, p = 0.003 at 12 months, p = 0.02 at 24 months and p = 0.001 at 36 months). No difference in 36-month survival after LT was seen, regardless of whatever the aetiology of the patient’s liver disease was HCV+ or HCV− (80.3% vs. 75%) and whether the steatosis in the graft was absent, mild or moderate/severe (79.7% vs. 73.9% vs. 81.1%). Among HCV+ patients no difference in three-year survival rate was seen between who received grafts with steatosis from <50 year or 50-year-old donor. Recipient 50 years old (OR 3.44, 95% CI 1.19−10), a poor liver function soon after LT (OR 5.93, 95% CI 1.50−23.5) and diabetes mellitus pre-LT (OR 4, 95% CI 1.47−10.71) were independent risk factors of death 36 months after LT. HCV aetiology (OR 6.34, 95% CI 2.2−13.5) was the only independent factor associated with fibrosis progression. Neither the donor’s age nor donor graft steatosis correlated with fibrosis progression after LT. Conclusions: Nearly 1/4 of HCV+ recipients have pre-cirrhosis/cirrhosis 3 years after LT. Older recipient, a poor liver function soon after LT and pre-LT diabetes mellitus are associated with poor outcome at 3-year postLT. Steatotic grafts do not seem to exacerbate the progression of fibrosis in HCV+ recipients, nor seem to negatively affect 3-year patient survival. 466 NATREMIA AND CHILD-TURCOTTE-PUGH (CTP) SCORE MAY IMPROVE THE SELECTION OF CANDIDATES FOR LIVER TRANSPLANTATION (LT) WITH LOW MODEL FOR END-STAGE LIVER DISEASE SCORE (MELD) S. Gitto1 , M. Biselli1 , A. Gramenzi1 , G. Vitale1 , S. Lorenzini1 , R. Di Donato1 , L. Brodosi1 , M.C. Morelli2 , G.L. Grazi2 , A.D. Pinna2 , M. Bernardi1 , P. Andreone1 , Bologna Liver Transplantation Group (BLTG). 1 Department of Clinical Medicine, 2 Department of General Surgery and Organ Transplantation, University of Bologna, Bologna, Italy E-mail: [email protected] Background and Aims: It is well known that the survival benefit of LT depends on candidate disease severity, as measured by MELD that is widely used for the organ allocation. It has been suggested that LT for patients with low MELD should be reconsidered. The aim of this study was to evaluate whether other factors were able to better select the low MELD candidates. Methods: The waiting list mortality of 452 cirrhotic patients consecutively listed for LT between January 2003 and October 2008 at the Bologna