Patterns of Early Allograft Dysfunction in Adult Live Donor Liver Transplantation: The A2ALL Experience.
BACKGROUND
Early allograft dysfunction (EAD) after living donor liver transplantation (LDLT) has often been attributed to inadequate graft size, and termed small-for-size syndrome. Early allograft dysfunction definitions include a variable constellation of findings, including hyperbilirubinemia, coagulopathy, encephalopathy, and ascites formation. Among putative causes of EAD after LDLT are excessive portal pressure and/or flow. Our objective was to evaluate patterns of EAD after LDLT.


METHODS
In this study, 631 LDLT recipients were monitored for complications, EAD (defined by postoperative day 7 bilirubin >10 mg/dL or international normalized ratio >1.6), and graft failure. Approximately 200 had portal venous and arterial pressure and flow measurements before and after LDLT. Portal inflow modification (splenic artery ligation, hemiportocaval shunt, or splenectomy) was performed at the discretion of the operating surgeon. Associations between EAD and recipient, donor, and transplant factors were examined using multivariable logistic regression.


RESULTS
Risk of EAD was associated with left lobe grafts, lower graft weight among left lobes, higher preoperative bilirubin, higher portal reperfusion pressure, higher donor age, and higher donor body mass index. The risk of graft loss within the first 90 days was 5.2 times higher for recipients with EAD versus those without EAD (P < 0.001).


CONCLUSIONS
Early allograft dysfunction can be defined using postoperative day 7 laboratory values that are highly predictive of early graft failure within 90 days. Risk factors associated with EAD after LDLT include: graft type and size, preoperative bilirubin, portal reperfusion pressure, donor age, and donor body mass index.
1 Department of Transplantation, Lahey Hospital and Medical Center, Burlington, MA. 2 Arbor Research Collaborative for Health, Ann Arbor, MI. 3 Center for Liver Disease and Transplantation, Columbia University, New York, NY. 4 Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA. 5 Department of Surgery, Northwestern University, Chicago, IL. 6 Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada. 7 Division of Transplantation, Harvard Medical School, Boston, MA. 8 Department of Surgery, University of California, San Francisco, San Francisco, CA. 9 Department of Surgery, University of Pennsylvania, Philadelphia, PA. 10 Department of Biostatistics, University of Michigan, Ann Arbor, MI. 11 Department of Surgery, University of Michigan, Ann Arbor, MI.
James J
JJ
Pomposelli
Nathan P
NP
Goodrich
Jean C
JC
Emond
Abhinav
A
Humar
Talia B
TB
Baker
David R
DR
Grant
Robert A
RA
Fisher
John P
JP
Roberts
Kim M
KM
Olthoff
Brenda W
BW
Gillespie
Robert M
RM
Merion
D000328:Adult; D000367:Age Factors; D000368:Aged; D064591:Allografts; D015331:Cohort Studies; D005260:Female; D006085:Graft Survival; D006801:Humans; D053208:Kaplan-Meier Estimate; D008099:Liver / Q000601:surgery; D017093:Liver Failure / Q000601:surgery*; D016031:Liver Transplantation; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D017082:Portal Pressure; D011169:Portal Vein; D055031:Primary Graft Dysfunction / Q000175:diagnosis*; D016016:Proportional Hazards Models; D012042:Registries; D012307:Risk Factors; D013997:Time Factors