Predictors of early graft survival after pediatric liver transplantation.
The objective of this study was to identify peritransplant predictors of early graft survival and posttransplant parameters that could be used to predict early graft outcomes after pediatric liver transplantation (PLT). The response of children to liver dysfunction after liver transplantation (LT) is poor. No data have been reported for early predictors of poor graft survival, which would potentially be valuable for rescuing children at risk after LT. A retrospective cohort study of 422 PLT procedures performed from 2000 to 2010 at a single center was conducted. Multiple peritransplant variables were analyzed. Univariate and multivariate analyses using receiver operating characteristic curves were performed to identify predictors of early graft loss (ie, at 30, 60, and 90 days). The number needed to treat (NNT) was calculated when the risk factors were identified. Comparisons with the Olthoff criteria for early graft dysfunction in adults were performed. The overall 30-, 60-, and 90-day graft survival rates were 93.6%, 92.6%, and 90.7%, respectively. A recipient age of 0 to 2 or 6 to 16 years, acute liver failure, and a posttransplant day 7 serum bilirubin level > 200 μmol/L were risk factors for graft loss in the 3-strata Cox models. The product of the peak aspartate aminotransferase (AST) level, day 2 international normalized ratio (INR) value, and day 7 bilirubin level [with 30-, 60-, and 90-day areas under the receiver operating characteristic curve (AUROCs) of 0.774, 0.752, and 0.715, respectively] and a day 7 bilirubin level > 200 μmol/L (with 30-, 60-, and 90-day AUROCs of 0.754, 0.661, and 0.635, respectively) provided excellent prediction rates for early graft loss (30-days for Day-7-bilirubin level > 200) in the pediatric population (sensitivity = 72.7%, specificity = 96.6%, positive predictive value = 95.5%, negative predictive value = 78%). The NNT with early retransplantation when the day 7 bilirubin level was >200 μmol/L was 2.17 (unadjusted) or 2.76 (adjusted for graft survival). In conclusion, 2 scores-the product of the peak AST level, day 2 INR value, and day 7 bilirubin level and a posttransplant day 7 bilirubin level > 200 μmol/L-have been identified as clinically valuable tools with high accuracy for predicting early graft loss. A more aggressive attitude to considering early retransplantation in this group may further improve survival after LT.
Institute of Liver Studies, King's Health Partners, King's College Hospital, London, United Kingdom; Unit of Hepatobiliary Surgery and Liver Transplantation, IMIBIC Reina Sofia University Hospital, Cordoba, Spain. rubenciria@hotmail.com
Ruben
R
Ciria
Diego
D
Davila
Shirin E
SE
Khorsandi
Faisal
F
Dar
Roberto
R
Valente
Javier
J
Briceño
Hector
H
Vilca-Melendez
Anil
A
Dhawan
Mohamed
M
Rela
Nigel D
ND
Heaton
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006085:Graft Survival; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D017093:Liver Failure / Q000628:therapy*; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D015999:Multivariate Analysis; D010372:Pediatrics / Q000379:methods; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012306:Risk; D013997:Time Factors; D016896:Treatment Outcome