title: Primary non-function is frequently associated with fatty liver allografts and high mortality after re-transplantation.
abstract: The shortage of liver donations demands the use of suboptimal grafts with steatosis being a frequent finding. Although ≤30% macrovesicular steatosis is considered to be safe the risk for primary non-function (PNF) and outcome after re-transplantation (re-OLT) is unknown.
  
  
  
  Among 1205 orthotopic liver transplantations performed at our institution the frequency, survival and reason of re-OLT were evaluated. PNF (group A) cases and those with initial transplant function but subsequent need for re-OLT (group B) were analysed. Histopathology and clinical judgement determined the cause of PNF and included an assessment of hepatic steatosis. Additionally, survival of fatty liver allografts (group C) not requiring re-OLT was considered in Kaplan-Meier and multivariate regression analysis.
  
  
  
  A total of 77 high urgency re-OLTs were identified and included 39 PNF cases. Nearly 70% of PNF cases were due to primary fatty liver allografts. The 3-month in-hospital mortality for PNF cases after re-OLT was 46% and the mean survival after re-OLT was 0.5 years as compared to 5.2 and 5.1 years for group B, C, respectively, (P<.008). In multivariate Cox regression analysis only hepatic steatosis was associated with an inferior survival (HR 4.272, P=.002). The MELD score, donor BMI, age, cold ischaemic time, ICU stay, serum sodium and transaminases did not influence overall survival.
  
  
  
  Our study highlights fatty liver allografts to be a major cause for PNF with excessive mortality after re-transplantation. The findings demand the development of new methods to predict risk for PNF of fatty liver allografts.
authors.affiliation: Department of General-, Visceral- and Transplantation Surgery, Hannover, Germany.
authors.forename: Ulf
authors.initials: U
authors.lastname: Kulik
authors.affiliation: Department of General-, Visceral- and Transplantation Surgery, Hannover, Germany.
authors.forename: Frank
authors.initials: F
authors.lastname: Lehner
authors.affiliation: Department of General-, Visceral- and Transplantation Surgery, Hannover, Germany.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Klempnauer
authors.affiliation: Centre for Pharmacology and Toxicology, Hannover Medical School, Hannover, Germany.
authors.forename: Jürgen
authors.identifier: 0000-0003-1558-9519
authors.initials: J
authors.lastname: Borlak
mesh_terms: D000328:Adult; D000368:Aged; D064591:Allografts / Q000473:pathology / Q000706:statistics & numerical data*; D005234:Fatty Liver / Q000150:complications* / Q000473:pathology; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D008099:Liver / Q000473:pathology; D017093:Liver Failure / Q000209:etiology*; D008111:Liver Function Tests; D016031:Liver Transplantation / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012086:Reoperation / Q000401:mortality*; D012189:Retrospective Studies; D055815:Young Adult
keywords: fatty liver allografts; in-hospital mortality; long-term survival; primary non-function; re-transplantation