Decision for retransplantation of the liver: an experience- and cost-based analysis.
OBJECTIVE
To determine the patient factors affecting patient outcome of first liver retransplantation at a single center to help in the decision process for retransplantation.


BACKGROUND
Given the critical organ shortage, one of the most controversial questions is whether hepatic retransplantation, the only chance of survival for patients with a failing first organ, should be offered liberally despite its greater cost, worse survival, and the inevitable denial of access to primary transplantation to other patients due to the depletion of an already-limited organ supply. The authors' experience of 139 consecutive retransplantations was reviewed to evaluate the results of retransplantation and to identify the factors that could improve the results.


METHODS
From 1986 to 2000, 1,038 patients underwent only one liver transplant and 139 patients underwent a first retransplant at the authors' center (first retransplantation rate = 12%). Multivariate analysis was performed to identify variables, excluding intraoperative and donor variables, associated with graft and patient long-term survival following first retransplantation. Lengths of hospital and intensive care unit stay and hospital charges incurred during the transplantation admissions were compared for retransplanted patients and primary-transplant patients.


RESULTS
One-year, 5-year, and 10-year graft and patient survival rates following retransplantation were 54.0%, 42.5%, 36.8% and 61.2%, 53.7%, and 50.1%, respectively. These percentages were significantly less than those following a single hepatic transplantation at the authors' center during the same period (82.3%, 72.1%, and 66.9%, respectively). On multivariate analysis, three patient variables were significantly associated with a poorer patient outcome: urgency of retransplantation (excluding primary nonfunction), age, and creatinine. Primary nonfunction as an indication for retransplantation, total bilirubin, and factor II level were associated with a better prognosis. The final model was highly predictive of survival: according to the combination of the factors affecting outcome, 5-year patient survival rates varied from 15% to 83%. Retransplant patients had significantly longer hospital and intensive care unit stays and accumulated significantly higher total hospital charges than those receiving only one transplant. CONCLUSIONS These data confirm the utility of retransplantation in the elective situation. In the emergency setting, retransplantation should be used with discretion, and it should be avoided in subgroups of patients with little chance of success.
Azoulay
Daniel
D
Hepatobiliary Center, Hôspital Paul Brousse, Assitance Publique-Hôpitaux de Paris and Université Paris Sud, Villejuif, France. daniel.zaoulay@pbr.ap-hop-paris.fr
Linhares
Marcello M
MM
Huguet
Emmanuel
E
Delvart
Valérie
V
Castaing
Denis
D
Adam
René
R
Ichai
Philippe
P
Saliba
Faouzi
F
Lemoine
Antoinette
A
Samuel
Didier
D
Bismuth
Henri
H
D000328:Adult; D000704:Analysis of Variance; D016001:Confidence Intervals; D003362:Cost-Benefit Analysis; D003657:Decision Making; D005260:Female; D005500:Follow-Up Studies; D005602:France; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D017093:Liver Failure / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D008111:Liver Function Tests; D016031:Liver Transplantation / Q000009:adverse effects* / Q000191:economics* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011336:Probability; D016016:Proportional Hazards Models; D012042:Registries; D012086:Reoperation / Q000592:standards / Q000639:trends; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D016019:Survival Analysis