title: The evolution of liver transplantation during 3 decades: analysis of 5347 consecutive liver transplants at a single center.
abstract: OBJECTIVE
  To analyze a 28-year single-center experience with orthotopic liver transplantation (OLT) for patients with irreversible liver failure.
  
  
  BACKGROUND
  The implementation of the model for end-stage liver disease (MELD) in 2002 represented a fundamental shift in liver donor allocation to recipients with the highest acuity, raising concerns about posttransplant outcome and morbidity.
  
  
  METHODS
  Outcomes and factors affecting survival were analyzed in 5347 consecutive OLTs performed in 3752 adults and 822 children between 1984 and 2012, including comparisons of recipient and donor characteristics, graft and patient outcomes, and postoperative morbidity before (n = 3218) and after (n = 2129) implementation of the MELD allocation system. Independent predictors of survival were identified.
  
  
  RESULTS
  Overall, 1-, 5-, 10-, and 20-year patient and graft survival estimates were 82%, 70%, 63%, 52%, and 73%, 61%, 54%, 43%, respectively. Recipient survival was best in children with biliary atresia and worst in adults with malignancy. Post-MELD era recipients were older (54 vs 49, P < 0.001), more likely to be hospitalized (50% vs 47%, P = 0.026) and receiving pretransplant renal replacement therapy (34% vs 12%, P < 0.001), and had significantly greater laboratory MELD scores (28 vs 19, P < 0.001), longer wait-list times (270 days vs 186 days, P < 0.001), and pretransplant hospital stays (10 days vs 8 days, P < 0.001). Despite increased acuity, post-MELD era recipients achieved superior 1-, 5-, and 10-year patient survival (82%, 70%, and 65% vs 77%, 66%, and 58%, P < 0.001) and graft survival (78%, 66%, and 61% vs 69%, 58%, and 51%, P < 0.001) compared with pre-MELD recipients. Of 17 recipient and donor variables, era of transplantation, etiology of liver disease, recipient and donor age, prior transplantation, MELD score, hospitalization at time of OLT, and cold and warm ischemia time were independent predictors of survival.
  
  
  CONCLUSIONS
  We present the world's largest reported single-institution experience with OLT. Despite increasing acuity in post-MELD era recipients, patient and graft survival continues to improve, justifying the "sickest first" allocation approach.
authors.affiliation: *Department of Surgery, Dumont-UCLA Transplant and Liver Cancer Centers, Pfleger Liver Institute, Los Angeles, CA; and Departments of †Pediatrics, ‡Medicine, §Anesthesiology, and ¶Division of General Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA.
authors.forename: Vatche G
authors.initials: VG
authors.lastname: Agopian
authors.forename: Henrik
authors.initials: H
authors.lastname: Petrowsky
authors.forename: Fady M
authors.initials: FM
authors.lastname: Kaldas
authors.forename: Ali
authors.initials: A
authors.lastname: Zarrinpar
authors.forename: Douglas G
authors.initials: DG
authors.lastname: Farmer
authors.forename: Hasan
authors.initials: H
authors.lastname: Yersiz
authors.forename: Curtis
authors.initials: C
authors.lastname: Holt
authors.forename: Michael
authors.initials: M
authors.lastname: Harlander-Locke
authors.forename: Johnny C
authors.initials: JC
authors.lastname: Hong
authors.forename: Abbas R
authors.initials: AR
authors.lastname: Rana
authors.forename: Robert
authors.initials: R
authors.lastname: Venick
authors.forename: Sue V
authors.initials: SV
authors.lastname: McDiarmid
authors.forename: Leonard I
authors.initials: LI
authors.lastname: Goldstein
authors.forename: Francisco
authors.initials: F
authors.lastname: Durazo
authors.forename: Sammy
authors.initials: S
authors.lastname: Saab
authors.forename: Steven
authors.initials: S
authors.lastname: Han
authors.forename: Victor
authors.initials: V
authors.lastname: Xia
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Hiatt
authors.forename: Ronald W
authors.initials: RW
authors.lastname: Busuttil
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000890:Anti-Infective Agents / Q000627:therapeutic use; D019072:Antibiotic Prophylaxis / Q000379:methods / Q000639:trends; D002648:Child; D002675:Child, Preschool; D004359:Drug Therapy, Combination; D058625:End Stage Liver Disease / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006085:Graft Survival; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods / Q000639:trends; D007223:Infant; D007231:Infant, Newborn; D016031:Liver Transplantation / Q000401:mortality / Q000639:trends; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care / Q000379:methods / Q000639:trends; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control; D012086:Reoperation / Q000706:statistics & numerical data / Q000639:trends; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000890:Anti-Infective Agents