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Outcomes of Liver Transplantation Using Organ Donation After Cardiac Death (DCD) Versus Organ Donation After Brain Death (DBD): A Single Center Experience
trends were stratified by liver disease etiology, UNOS region, sex, and race/ethnicity, and evaluated using the following intervals: 2005-6, 2007-8, 2009-10, 2011-12, and 2013-15. Comparisons of mean MELD scores across time periods and across groups utilized the Student's t-test. Comparisons of patients undergoing LT utilized two-tailed Fisher's exact test. Results: Overall, 2345 patients underwent LT for chronic HCV, 2546 for NASH, and 3331 for ETOH. Overall MELD at time of LT remained stable during this period (20.0 in 2005-6 to 20.6 in 2013-15, p=0.21). While the proportion of non-HCC patients with ETOH who received LT decreased significantly from 2005-6 to 2013-15 (58% to 51%, p=0.01), proportion of patients with NASH and chronic HCV who received LT remained stable. MELD at time of LT among ETOH patients increased from 21.7 in 2005-6 to 25.4 in 201315, p<0.01, whereas MELD among NASH patients remained stable (18.8 to 19.5, p=0.39). However, MELD scores among chronic HCV patients undergoing LT decreased significantly from 18.0 in 2005-6 to 15.6 in 2013-15, p <0.01. In the most recent time period 201315, patients with NASH and ETOH all had significantly higher MELD scores at time of LT compared to patients with chronic HCV (Figure). No disease-specific differences in MELD at LT were observed across race/ethnicities, sex, or UNOS regions. Conclusion: Among U.S. adults without HCC undergoing LT, overall MELD scores at time of LT have remained stable. However, MELD scores at time of LT among patients with ETOH increased significantly, whereas MELD at time of LT among chronic HCV patients decreased to their lowest levels in 2013-15. Understanding disparities in MELD scores required for adequate prioritization for LT among different groups will help guide future revisions of LT allocation policies.
Figure 1: HRQOL as measured by mean PROMIS domains across different MELDNa scores
OUTCOMES OF LIVER TRANSPLANTATION USING ORGAN DONATION AFTER CARDIAC DEATH (DCD) VERSUS ORGAN DONATION AFTER BRAIN DEATH (DBD): A SINGLE CENTER EXPERIENCE Abimbola Adike, Matthew Buras, Bara El Kurdi, Kunam S. Reddy, Adyr A. Moss, Bashar Aqel Introduction: Donation after cardiac death (DCD) liver allografts have been associated with primary non-function, ischemic cholangiopathy, hepatic artery stenosis and a higher retransplantation rate when compared with donation after brain death (DBD) allografts. The number of liver transplantation (LT) with DCD allografts has increased in the recent years. We present our experience with using this extended criteria donor grafts. Primary objective: To compare patient and graft survival between DCD and DBD allografts. Methods: We retrospectively reviewed all LTs performed at a major transplant center from January 2012 to November 2015. We excluded patients who received a combined liver and kidney transplant (n = 22), and those who received a split LT (n =4). Univariate analyses comparing the two groups was performed using chi-square test, fisher's exact test, t-test or Wilcoxon rank sum test. Kaplan-Meier curves were produced for survival and graft survival. The KM curves for the two groups were compared using the Log-Rank test. A p-value < 0.05 was considered significant. Results: So far, of 244 patients analyzed who have one year followup, 40 patients received DCD grafts, and 204 patients received DBD grafts. There was no difference in the recipient age, gender, BMI and match MELD scores of both groups (Table 1). The DBD recipients had a higher biological MELD score, (p = 0.01) while the DCD donors had a higher donor risk index (p<0.0001). Overall median follow up period was 30 months. Patient survival in DCD recipients was 94.8% at 1 year, and 82% at 4 years versus 95.6% at 1 year and 88.3% at 4 years in DBD recipients, p = 0.69 (Figure 1). Graft survival in DCD recipients was 92.% at 1 year, and 79.8% at 4 years versus 94.1% at 1 year and 81.9% at 4 years in DBD recipients, p = 0.77 (Figure 1). Non-anastomotic biliary strictures occurred in 25% of DCD organs versus 5.4% of DBD organs. Most cases of ischemic cholangiopathy were mild, managed endoscopically without any significant impact on graft or patient survival. Conclusion: With careful selection, LT with DCD organs is comparable to DBD organs and improved patient access to this life saving surgery.
Su1412 MODEL FOR END-STAGE LIVER DISEASE SODIUM SCORE IS NOT PREDICTIVE OF HEALTH-RELATED QUALITY OF LIFE IN LIVER TRANSPLANTATION CANDIDATES Jennifer Wang, George J. Stukenborg, Gold A. Adkins, Blake Niccum, Alex Zimmet, Curtis K. Argo, Jonathan G. Stine Background & Aim: Model for End-Stage Liver Disease Sodium (MELD-Na) score has been used to prioritize patients with chronic liver disease who are on the waiting list for liver transplantation. This study seeks to investigate whether a correlation exists between MELDNa score and health-related quality of life (HRQOL) in patients awaiting liver transplantation. Methods: Liver transplantation candidates at the University of Virginia completed the PatientReported Outcomes Measurement Information System (PROMIS) assessment via tablet computer (iPAD). Using scores calibrated to the general population (median 50), nine domains of health were assessed: anxiety, depression, fatigue, pain interference, physical function, sleep, instrumental support, social roles, and cognitive impairment. General linear regression models were constructed to assess the significance of differences in mean PROMIS domain score measurements for MELD-Na score. Results: Ninety-six liver transplant candidates with mean age of 55.2 +/- 9.3 years were enrolled. 61.5% were male and mean MELD-Na score was 15.6 +/- 6.4; 26.2% had MELD <10, 43.1% had MELD 10-19, 27.7% had MELD 20-29; and 3% had MELD >30; 21.5% had history of hepatocellular carcinoma. The top three etiologies of liver disease were chronic hepatitis C (30.8%), nonalcoholic steatohepatitis (27.7%) and alcoholic liver disease (20.0%). Subjects reported impaired physical function (41.6 +/- 8.4), cognitive function (45.9 +/- 9.7) and social roles (46.3 +/- 8.6) as well as higher levels of fatigue (57.4 +/- 8.9), pain interference (57.3 +/- 10.3), sleep disturbance (54.8 +/- 10.0), and instrumental support (58.4 +/- 8.0). No significant differences were demonstrated across different MELD score groups (10-19, 20-29, >30) when compared to the reference group (MELD <10) in any measured domain; however, there was a trend towards significance in MELD >30 group with MELD score correlating with level of anxiety (p=0.11) and in MELD 20-29 group in terms of physical function (p=0.07) when compared to the reference group. Conclusions: While liver transplant candidates have significantly impaired HRQOL across multiple domains of health, MELD-Na score was not predictive of impairment. MELD-Na score alone may not sufficiently identify patients most in need of liver transplantation. Incorporating HRQOL into standard organ allocation policy may create a more equitable system reframing which patients would benefit the most from transplantation and should be validated with future study.
S-1121
AASLD Abstracts
AASLD Abstracts
Su1413
Table 1: Demographics and outcomes by donor relationship
Su1416
AASLD Abstracts
RISK OF LATE-ONSET CMV INFECTION AFTER LIVER TRANSPLANTATION IS ASSOCIATED WITH RECIPIENT'S IFNL4 RS12979860 GENOTYPE Klara Chmelova, Sona Frankova, Milan Jirsa, Magdalena Neroldova, Pavel Trunecka, Julius Spicak, Jan Sperl Background and aims: Cytomegalovirus (CMV) infection represents a serious complication in liver transplant (LTx) recipients with a negative impact on post-transplant morbidity and treatment costs. The standard antiviral prophylaxis is adjusted according to donor and recipient pretransplant serostatus. The failure of CMV infection control in 10-20% LTx recipients shows that there is a need for a more individualised prophylaxis. The upstream intronic variant IFNL4 rs12979860 T (formerly known as IL28B), linked to functional frameshift mutation ss469415590 ∆G in IFNL4, and originally described as HCV clearance predictor, influences CMV replication as well. The aim of the study was to assess impact of IFNL4 variants on incidence of CMV episodes in LTx recipients. Methods: We retrospectively analysed 743 adult patients who underwent LTx owing to liver cirrhosis from 1996 to 2015. CMV prophylaxis was administered to all patients 6 months post-transplant (valaciclovir in seropositive, valganciclovir in seronegative recipients). Any event associated with increase of CMV DNA or pp65 positivity requiring antiviral treatment was considered as a CMV episode. The patients with a CMV episode were divided into subgroups according to its onset after LTx: early (<6 months) and late (≥6 months). Χ2 test was used to assess the significance of the differences between allelic frequencies. Results: 144/743 (19.4%) patients presented with at least one CMV episode. 102/144 patients had an early onset CMV episode, 42/144 patients suffered from the late onset CMV episode. The frequency of the IFNL4 rs12979860 genotypes was as follows: in patients without CMV episode (n= 599) CC 231 (38.6%), CT 295 (49.2%), TT 73 (12.2%), in patients with the early onset (n= 102) CC 34 (33.3%), CT 55 (53.9%), TT 13 (12.8%) and in patients with the late onset (n= 42) CC 25 (59.5%), CT 13 (31%) and TT 4 (9.5%). The genotypes distribution in the early onset subgroup was comparable with the group without CMV episode, while the late onset subgroup had higher CC genotype frequency. In the early onset subgroup, the influence of IFNL4 genotype was significant neither in the allelic (CC vs. CT+TT, p=0.31) nor in the recessive model (CC+CT vs. TT, p=0.87), but in the late onset subgroup, T allele carriage (CC vs. CT+TT) had a protective impact against CMV occurrence, OR 2.3 (95% CI 1.24.4, p=0.007). Conclusions: Our data showed that IFNL4 rs12979860 T allele carriers had lower risk of late onset CMV episode after CMV prophylaxis cessation, but it had no impact on early onset CMV episode occurrence during antiviral prophylaxis. Our data may contribute to individualisation of the length of CMV prophylaxis.
SD = Standard deviation; NASH = Non-alcoholic steatohepatitis, PBC = Primary biliary cholangitis; PSC = Primary sclerosing cholangitis, MELD = Model for End-stage liver disease, BMI = Body mass index; LOS = Length of stay, n/a = not applicable
Su1417 SUSTAINED POST-TRANSPLANT DIABETES IS ASSOCIATED WITH AN INCREASED RISK OF MAJOR CARDIOVASCULAR EVENTS FOLLOWING LIVER TRANSPLANTATION Giorgio A. Roccaro, David S. Goldberg, Wei-Ting Hwang, Yu-Xiao Yang Background and Aims: Cardiovascular disease (CVD) is a leading cause of death among liver transplant (LT) recipients. With non-alcoholic steatohepatitis (NASH) soon to be the leading indication for LT in the United States, the increasing burden of post-transplant metabolic diseases, including diabetes mellitus (DM), may result in substantial increases in cardiovascular related morbidity and mortality. While DM is a risk factor for CVD after LT, it is unknown if the risk of major cardiovascular events (MCE) differs among LT recipients with varying diabetic states. Methods: We performed a retrospective cohort study of LT recipients at the Hospital of the University of Pennsylvania (2003-2014, n=1304) to compare the risk of MCE among LT recipients with 1) no history of DM prior to or following LT (normal), 2) pre-LT DM: DM diagnosed prior to date of LT, 3) transient post-transplant DM (t-PTDM): DM requiring treatment for ≥1 month and <6 months following LT, and 4) sustained post-transplant DM (s-PTDM): DM requiring treatment or diagnosed ≥6 months from date of LT. DM status was defined using validated algorithms and manual chart review. Patients with acute liver failure, prior or multi-organ transplant, prior history of MCE, and <6 months survival post-LT were excluded. MCE, defined as myocardial infarction, stroke, peripheral artery disease requiring revascularization, and death attributed to CVD, were identified using validated algorithms and manual chart review. Competing risk regression methods, with non-CVD related death as a competing risk, were used to compare risk of MCE among LT recipients according to diabetes status. A comprehensive list of potential confounders was tested for association with MCE and for a change in effect of the relationship between diabetes status and MCE. Results: 994 eligible patients were analyzed (Table 1). Median follow up was 54.7 months (Range: 6.1-152.9). Overall, 119 (12%) patients experienced a MCE. Adjusting for gender, race, age at LT, etiology of liver disease, hypertension, hyperlipidemia, year of LT, and smoking, s-PTDM had the highest cumulative incidence of MCE (Figure 1). In multivariable analyses, s-PTDM was the only diabetes exposure associated with significantly greater risk of MCE (subdistribution hazard ratio (sHR) 1.93, 95% CI 1.20-3.10) than normal patients. Patients with s-PTDM had a greater risk of MCE than patients with pre-LT DM (sHR 1.74, 95% CI 1.10-2.76) and t-PTDM (sHR 2.47, 95% CI 1.19-5.11). Conclusions: Patients with s-PTDM have significantly greater risk of MCE than patients with pre-LT DM. While pre-LT DM has been traditionally associated with increased risk of MCE, the cause-specific hazard may be greater in patients with s-PTDM. Further studies are needed to investigate the role of glycemic control, lifestyle interventions and pharmacoprevention on CVD risk in patients with s-PTDM.
Figure 1: KM curves of patient and graft survival
Su1414 SUBCLINICAL PULMONARY HYPERTENSION IS A STRONG RISK OF POST LIVING DONOR LIVER TRANSPLANTATION SURVIVAL FOR LIVER CIRRHOSIS Yosuke Saragai, Akinobu Takaki, Yuzo Umeda, Tetsuya Yasunaka, Ryuji Kaku, Kazufumi Nakamura, Takahito Yagi, Susumu Shinoura, Ryuichi Yoshida, Daisuke Nobuoka, Takuya Adachi, Yasuyuki Shimomura, Nozomu Wada, Kenji Kuwaki, Fusao Ikeda, Hideki Onishi, Hidenori Shiraha, Shinichiro Nakamura, Hiroshi Ito, Toshiyoshi Fujiwara, Hiroyuki Okada Pulmonary complications of liver cirrhosis are known as Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH). HPS is characterized by vascular dilatation and hyperdynamic circulation, while POPH is characterized by vasoconstriction with fibrous obliteration of the vascular bed. Definitely diagnosed POPH is rarely found, while indicates worse survival after orthotopic liver transplantation (OLT). The present objective is to investigate the clinical impact of frequently found subclinical HPS and POPH on post-living donor related OLT (LDLT) survival. We recruited liver cirrhosis patients admitted to our hospital as liver transplantation candidates. Patients exhibiting pO2 lower than 80 mmHg and AaDO2 ≥ 15 mmHg were categorized as potentially having HPS (subclinical HPS; 29/85). Patients exhibiting a tricuspid regurgitation pressure gradient ≥ 25 mmHg were categorized as potentially having POPH (subclinical POPH; 34/76). Clinical course after LDLT was investigated according to known post-OLT survival related factors and subclinical HPS or subclinical POPH. Subclinical POPH and high Mayo end stage liver disease (MELD) score were correlated with one year worse survival. Subclinical POPH and high aged donor were correlated with median 40 months survival after LDLT. In conclusion, subclinical POPH is a definite survival defining factor after LDLT that might be controlled before or during operation.
AASLD Abstracts
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Figure 1: HRQOL as measured by mean PROMIS domains across different MELDNa scores
OUTCOMES OF LIVER TRANSPLANTATION USING ORGAN DONATION AFTER CARDIAC DEATH (DCD) VERSUS ORGAN DONATION AFTER BRAIN DEATH (DBD): A SINGLE CENTER EXPERIENCE Abimbola Adike, Matthew Buras, Bara El Kurdi, Kunam S. Reddy, Adyr A. Moss, Bashar Aqel Introduction: Donation after cardiac death (DCD) liver allografts have been associated with primary non-function, ischemic cholangiopathy, hepatic artery stenosis and a higher retransplantation rate when compared with donation after brain death (DBD) allografts. The number of liver transplantation (LT) with DCD allografts has increased in the recent years. We present our experience with using this extended criteria donor grafts. Primary objective: To compare patient and graft survival between DCD and DBD allografts. Methods: We retrospectively reviewed all LTs performed at a major transplant center from January 2012 to November 2015. We excluded patients who received a combined liver and kidney transplant (n = 22), and those who received a split LT (n =4). Univariate analyses comparing the two groups was performed using chi-square test, fisher's exact test, t-test or Wilcoxon rank sum test. Kaplan-Meier curves were produced for survival and graft survival. The KM curves for the two groups were compared using the Log-Rank test. A p-value < 0.05 was considered significant. Results: So far, of 244 patients analyzed who have one year followup, 40 patients received DCD grafts, and 204 patients received DBD grafts. There was no difference in the recipient age, gender, BMI and match MELD scores of both groups (Table 1). The DBD recipients had a higher biological MELD score, (p = 0.01) while the DCD donors had a higher donor risk index (p<0.0001). Overall median follow up period was 30 months. Patient survival in DCD recipients was 94.8% at 1 year, and 82% at 4 years versus 95.6% at 1 year and 88.3% at 4 years in DBD recipients, p = 0.69 (Figure 1). Graft survival in DCD recipients was 92.% at 1 year, and 79.8% at 4 years versus 94.1% at 1 year and 81.9% at 4 years in DBD recipients, p = 0.77 (Figure 1). Non-anastomotic biliary strictures occurred in 25% of DCD organs versus 5.4% of DBD organs. Most cases of ischemic cholangiopathy were mild, managed endoscopically without any significant impact on graft or patient survival. Conclusion: With careful selection, LT with DCD organs is comparable to DBD organs and improved patient access to this life saving surgery.
Su1412 MODEL FOR END-STAGE LIVER DISEASE SODIUM SCORE IS NOT PREDICTIVE OF HEALTH-RELATED QUALITY OF LIFE IN LIVER TRANSPLANTATION CANDIDATES Jennifer Wang, George J. Stukenborg, Gold A. Adkins, Blake Niccum, Alex Zimmet, Curtis K. Argo, Jonathan G. Stine Background & Aim: Model for End-Stage Liver Disease Sodium (MELD-Na) score has been used to prioritize patients with chronic liver disease who are on the waiting list for liver transplantation. This study seeks to investigate whether a correlation exists between MELDNa score and health-related quality of life (HRQOL) in patients awaiting liver transplantation. Methods: Liver transplantation candidates at the University of Virginia completed the PatientReported Outcomes Measurement Information System (PROMIS) assessment via tablet computer (iPAD). Using scores calibrated to the general population (median 50), nine domains of health were assessed: anxiety, depression, fatigue, pain interference, physical function, sleep, instrumental support, social roles, and cognitive impairment. General linear regression models were constructed to assess the significance of differences in mean PROMIS domain score measurements for MELD-Na score. Results: Ninety-six liver transplant candidates with mean age of 55.2 +/- 9.3 years were enrolled. 61.5% were male and mean MELD-Na score was 15.6 +/- 6.4; 26.2% had MELD <10, 43.1% had MELD 10-19, 27.7% had MELD 20-29; and 3% had MELD >30; 21.5% had history of hepatocellular carcinoma. The top three etiologies of liver disease were chronic hepatitis C (30.8%), nonalcoholic steatohepatitis (27.7%) and alcoholic liver disease (20.0%). Subjects reported impaired physical function (41.6 +/- 8.4), cognitive function (45.9 +/- 9.7) and social roles (46.3 +/- 8.6) as well as higher levels of fatigue (57.4 +/- 8.9), pain interference (57.3 +/- 10.3), sleep disturbance (54.8 +/- 10.0), and instrumental support (58.4 +/- 8.0). No significant differences were demonstrated across different MELD score groups (10-19, 20-29, >30) when compared to the reference group (MELD <10) in any measured domain; however, there was a trend towards significance in MELD >30 group with MELD score correlating with level of anxiety (p=0.11) and in MELD 20-29 group in terms of physical function (p=0.07) when compared to the reference group. Conclusions: While liver transplant candidates have significantly impaired HRQOL across multiple domains of health, MELD-Na score was not predictive of impairment. MELD-Na score alone may not sufficiently identify patients most in need of liver transplantation. Incorporating HRQOL into standard organ allocation policy may create a more equitable system reframing which patients would benefit the most from transplantation and should be validated with future study.
S-1121
AASLD Abstracts
AASLD Abstracts
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Table 1: Demographics and outcomes by donor relationship
Su1416
AASLD Abstracts
RISK OF LATE-ONSET CMV INFECTION AFTER LIVER TRANSPLANTATION IS ASSOCIATED WITH RECIPIENT'S IFNL4 RS12979860 GENOTYPE Klara Chmelova, Sona Frankova, Milan Jirsa, Magdalena Neroldova, Pavel Trunecka, Julius Spicak, Jan Sperl Background and aims: Cytomegalovirus (CMV) infection represents a serious complication in liver transplant (LTx) recipients with a negative impact on post-transplant morbidity and treatment costs. The standard antiviral prophylaxis is adjusted according to donor and recipient pretransplant serostatus. The failure of CMV infection control in 10-20% LTx recipients shows that there is a need for a more individualised prophylaxis. The upstream intronic variant IFNL4 rs12979860 T (formerly known as IL28B), linked to functional frameshift mutation ss469415590 ∆G in IFNL4, and originally described as HCV clearance predictor, influences CMV replication as well. The aim of the study was to assess impact of IFNL4 variants on incidence of CMV episodes in LTx recipients. Methods: We retrospectively analysed 743 adult patients who underwent LTx owing to liver cirrhosis from 1996 to 2015. CMV prophylaxis was administered to all patients 6 months post-transplant (valaciclovir in seropositive, valganciclovir in seronegative recipients). Any event associated with increase of CMV DNA or pp65 positivity requiring antiviral treatment was considered as a CMV episode. The patients with a CMV episode were divided into subgroups according to its onset after LTx: early (<6 months) and late (≥6 months). Χ2 test was used to assess the significance of the differences between allelic frequencies. Results: 144/743 (19.4%) patients presented with at least one CMV episode. 102/144 patients had an early onset CMV episode, 42/144 patients suffered from the late onset CMV episode. The frequency of the IFNL4 rs12979860 genotypes was as follows: in patients without CMV episode (n= 599) CC 231 (38.6%), CT 295 (49.2%), TT 73 (12.2%), in patients with the early onset (n= 102) CC 34 (33.3%), CT 55 (53.9%), TT 13 (12.8%) and in patients with the late onset (n= 42) CC 25 (59.5%), CT 13 (31%) and TT 4 (9.5%). The genotypes distribution in the early onset subgroup was comparable with the group without CMV episode, while the late onset subgroup had higher CC genotype frequency. In the early onset subgroup, the influence of IFNL4 genotype was significant neither in the allelic (CC vs. CT+TT, p=0.31) nor in the recessive model (CC+CT vs. TT, p=0.87), but in the late onset subgroup, T allele carriage (CC vs. CT+TT) had a protective impact against CMV occurrence, OR 2.3 (95% CI 1.24.4, p=0.007). Conclusions: Our data showed that IFNL4 rs12979860 T allele carriers had lower risk of late onset CMV episode after CMV prophylaxis cessation, but it had no impact on early onset CMV episode occurrence during antiviral prophylaxis. Our data may contribute to individualisation of the length of CMV prophylaxis.
SD = Standard deviation; NASH = Non-alcoholic steatohepatitis, PBC = Primary biliary cholangitis; PSC = Primary sclerosing cholangitis, MELD = Model for End-stage liver disease, BMI = Body mass index; LOS = Length of stay, n/a = not applicable
Su1417 SUSTAINED POST-TRANSPLANT DIABETES IS ASSOCIATED WITH AN INCREASED RISK OF MAJOR CARDIOVASCULAR EVENTS FOLLOWING LIVER TRANSPLANTATION Giorgio A. Roccaro, David S. Goldberg, Wei-Ting Hwang, Yu-Xiao Yang Background and Aims: Cardiovascular disease (CVD) is a leading cause of death among liver transplant (LT) recipients. With non-alcoholic steatohepatitis (NASH) soon to be the leading indication for LT in the United States, the increasing burden of post-transplant metabolic diseases, including diabetes mellitus (DM), may result in substantial increases in cardiovascular related morbidity and mortality. While DM is a risk factor for CVD after LT, it is unknown if the risk of major cardiovascular events (MCE) differs among LT recipients with varying diabetic states. Methods: We performed a retrospective cohort study of LT recipients at the Hospital of the University of Pennsylvania (2003-2014, n=1304) to compare the risk of MCE among LT recipients with 1) no history of DM prior to or following LT (normal), 2) pre-LT DM: DM diagnosed prior to date of LT, 3) transient post-transplant DM (t-PTDM): DM requiring treatment for ≥1 month and <6 months following LT, and 4) sustained post-transplant DM (s-PTDM): DM requiring treatment or diagnosed ≥6 months from date of LT. DM status was defined using validated algorithms and manual chart review. Patients with acute liver failure, prior or multi-organ transplant, prior history of MCE, and <6 months survival post-LT were excluded. MCE, defined as myocardial infarction, stroke, peripheral artery disease requiring revascularization, and death attributed to CVD, were identified using validated algorithms and manual chart review. Competing risk regression methods, with non-CVD related death as a competing risk, were used to compare risk of MCE among LT recipients according to diabetes status. A comprehensive list of potential confounders was tested for association with MCE and for a change in effect of the relationship between diabetes status and MCE. Results: 994 eligible patients were analyzed (Table 1). Median follow up was 54.7 months (Range: 6.1-152.9). Overall, 119 (12%) patients experienced a MCE. Adjusting for gender, race, age at LT, etiology of liver disease, hypertension, hyperlipidemia, year of LT, and smoking, s-PTDM had the highest cumulative incidence of MCE (Figure 1). In multivariable analyses, s-PTDM was the only diabetes exposure associated with significantly greater risk of MCE (subdistribution hazard ratio (sHR) 1.93, 95% CI 1.20-3.10) than normal patients. Patients with s-PTDM had a greater risk of MCE than patients with pre-LT DM (sHR 1.74, 95% CI 1.10-2.76) and t-PTDM (sHR 2.47, 95% CI 1.19-5.11). Conclusions: Patients with s-PTDM have significantly greater risk of MCE than patients with pre-LT DM. While pre-LT DM has been traditionally associated with increased risk of MCE, the cause-specific hazard may be greater in patients with s-PTDM. Further studies are needed to investigate the role of glycemic control, lifestyle interventions and pharmacoprevention on CVD risk in patients with s-PTDM.
Figure 1: KM curves of patient and graft survival
Su1414 SUBCLINICAL PULMONARY HYPERTENSION IS A STRONG RISK OF POST LIVING DONOR LIVER TRANSPLANTATION SURVIVAL FOR LIVER CIRRHOSIS Yosuke Saragai, Akinobu Takaki, Yuzo Umeda, Tetsuya Yasunaka, Ryuji Kaku, Kazufumi Nakamura, Takahito Yagi, Susumu Shinoura, Ryuichi Yoshida, Daisuke Nobuoka, Takuya Adachi, Yasuyuki Shimomura, Nozomu Wada, Kenji Kuwaki, Fusao Ikeda, Hideki Onishi, Hidenori Shiraha, Shinichiro Nakamura, Hiroshi Ito, Toshiyoshi Fujiwara, Hiroyuki Okada Pulmonary complications of liver cirrhosis are known as Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH). HPS is characterized by vascular dilatation and hyperdynamic circulation, while POPH is characterized by vasoconstriction with fibrous obliteration of the vascular bed. Definitely diagnosed POPH is rarely found, while indicates worse survival after orthotopic liver transplantation (OLT). The present objective is to investigate the clinical impact of frequently found subclinical HPS and POPH on post-living donor related OLT (LDLT) survival. We recruited liver cirrhosis patients admitted to our hospital as liver transplantation candidates. Patients exhibiting pO2 lower than 80 mmHg and AaDO2 ≥ 15 mmHg were categorized as potentially having HPS (subclinical HPS; 29/85). Patients exhibiting a tricuspid regurgitation pressure gradient ≥ 25 mmHg were categorized as potentially having POPH (subclinical POPH; 34/76). Clinical course after LDLT was investigated according to known post-OLT survival related factors and subclinical HPS or subclinical POPH. Subclinical POPH and high Mayo end stage liver disease (MELD) score were correlated with one year worse survival. Subclinical POPH and high aged donor were correlated with median 40 months survival after LDLT. In conclusion, subclinical POPH is a definite survival defining factor after LDLT that might be controlled before or during operation.
AASLD Abstracts
S-1122