Preoperative and intraoperative predictors of postoperative morbidity, poor graft function, and early rejection in 190 patients undergoing liver transplantation.

HYPOTHESIS Preoperative and intraoperative variables predict in part adverse outcome after liver transplantation. DESIGN Prospective, blinded, cohort study. SETTING Tertiary care hospital. SUBJECTS A total of 190 adult patients undergoing primary liver transplantation. MAIN OUTCOME MEASURE Adverse outcome was prospectively defined as either in-hospital death or prolonged postoperative hospitalization (>14 days) associated with morbidity. Potential preoperative and intraoperative risk factors were collected. Associations were tested by univariate analysis followed by multivariate analysis in which preoperative factors were entered before intraoperative factors. RESULTS Adverse outcome occurred in 44.7% of patients. Incidences of other complications were as follows: in-hospital mortality (8.4%), primary graft nonfunction (4.2%), poor early graft function (1.1%), and early rejection (31.2%). Univariate predictors of adverse outcome were United Network for Organ Sharing status (P =.003), Child-Turcotte-Pugh score (P =.02), POSSUM physiological score (P =.002), recipient age (P =.01), preoperative serum high-density lipoprotein cholesterol level (P =.03), preoperative serum creatinine level (P =.002), preoperative serum total IgG level (P =.004), duration in hospital preoperatively (P =.03), operative duration (P<.001), allogeneic erythrocyte transfusions (P<.001), total intraoperative fluids (P =.002), and use of inotropic agents (P =.01). In the final multivariate model, predictors of adverse outcome were United Network for Organ Sharing status (P =.03), recipient age (P =.002), and total intraoperative fluids (P =.04). Most patients who died or had a prolonged hospitalization exhibited dysfunction of more than 1 organ system, including pulmonary, renal, and infectious complications. CONCLUSIONS Adverse outcome occurs frequently after liver transplantation, usually involves multiple organ systems, and is predicted in part by several preoperative and intraoperative factors.

[1]  R. Busuttil,et al.  Predictors of Survival After In Vivo Split Liver Transplantation: Analysis of 110 Consecutive Patients , 2000, Annals of surgery.

[2]  J. Findlay,et al.  Poor prediction of blood transfusion requirements in adult liver transplantations from preoperative variables. , 2000, Journal of clinical anesthesia.

[3]  J. Roberts,et al.  The effect of the volume of procedures at transplantation centers on mortality after liver transplantation. , 1999, The New England journal of medicine.

[4]  S. Opal,et al.  Relationship between plasma levels of lipopolysaccharide (LPS) and LPS-binding protein in patients with severe sepsis and septic shock. , 1999, The Journal of infectious diseases.

[5]  C. Bodian,et al.  Retransplantation for late liver graft failure: Predictors of mortality , 2000, Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society.

[6]  L. Grande,et al.  Liver transplantation in patients with non-biliary cirrhosis: prognostic value of preoperative factors , 1998 .

[7]  M. Slooff,et al.  Gastric mucosal pH is associated with initial graft function but is not a predictor of major morbidity after liver transplantation. , 1997, Liver transplantation and surgery : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society.

[8]  T. Fishbein,et al.  Use of livers with microvesicular fat safely expands the donor pool. , 1997, Transplantation.

[9]  C. Wynter,et al.  Endotoxin levels in donors and recipients during orthotopic liver transplantation. , 1997, The Australian and New Zealand journal of surgery.

[10]  A. Myc,et al.  The level of lipopolysaccharide-binding protein is significantly increased in plasma in patients with the systemic inflammatory response syndrome , 1997, Clinical and diagnostic laboratory immunology.

[11]  W. White,et al.  Relationship of preoperative antiendotoxin core antibodies and adverse outcomes following cardiac surgery. , 1997, JAMA.

[12]  P. Barie,et al.  Low lipid concentrations in critical illness: implications for preventing and treating endotoxemia. , 1996, Critical care medicine.

[13]  S. Knechtle,et al.  PRETRANSPLANT STATUS AND PATIENT SURVIVAL FOLLOWING LIVER TRANSPLANTATION , 1995, Transplantation.

[14]  S. Blanot,et al.  Circulating endotoxins and postreperfusion syndrome during orthotopic liver transplantation. , 1995, Transplantation.

[15]  C. C. Coffin,et al.  Reconstituted high-density lipoprotein neutralizes gram-negative bacterial lipopolysaccharides in human whole blood , 1995, Infection and immunity.

[16]  K. Mészáros,et al.  Immunoreactivity and bioactivity of lipopolysaccharide-binding protein in normal and heat-inactivated sera , 1995, Infection and immunity.

[17]  D. Abramowicz,et al.  Systemic release of interleukin‐10 during orthotopic liver transplantation , 1994, Hepatology.

[18]  L. Grande,et al.  Predictive factors of early postoperative graft function in human liver transplantation , 1994, Hepatology.

[19]  P. Clavien,et al.  Definition and Classification of Negative Outcomes in Solid Organ Transplantation Application in Liver Transplantation , 1994, Annals of surgery.

[20]  S. Carroll,et al.  Measurement of bactericidal/permeability-increasing protein in human body fluids by sandwich ELISA. , 1994, Journal of immunological methods.

[21]  S. Blanot,et al.  Circulating endotoxins during orthotopic liver transplantation and post-reperfusion syndrome , 1993, The Lancet.

[22]  J. Hurley,et al.  Endotoxin and tumor necrosis factor levels and hemodynamics during human liver transplantation. , 1993, Transplantation proceedings.

[23]  S. Hofbauer,et al.  Intraoperative course and prognostic significance of endotoxin, tumor necrosis factor-alpha and interleukin-6 in liver transplant recipients. , 1991, Immunobiology.

[24]  R. Steininger,et al.  Intraoperative estimation of endotoxin, TNF alpha, and IL-6 in orthotopic liver transplantation and their relation to rejection and postoperative infection. , 1991, Transplantation.

[25]  G. P. Copeland,et al.  POSSUM: A scoring system for surgical audit , 1991, The British journal of surgery.

[26]  M. Gnant,et al.  Immediate graft function after OLT clears endotoxins. , 1990, Transplantation proceedings.

[27]  D. V. van Thiel,et al.  Liver transplantation (2). , 1989, The New England journal of medicine.

[28]  T. Starzl,et al.  Liver transplantation. , 1989, The Johns Hopkins medical journal.

[29]  T. Starzl,et al.  Endotoxemia and human liver transplantation. , 1989, Transplantation proceedings.

[30]  B. Langer,et al.  Predictors of graft function following liver transplantation. , 1989, Transplantation proceedings.

[31]  P. Stock,et al.  Factors influencing early survival after liver transplantation. , 1989, American journal of surgery.

[32]  G. Barclay,et al.  Serological relationships between Escherichia coli and Salmonella smooth- and rough-mutant lipopolysaccharides as revealed by enzyme-linked immunosorbent assay for human immunoglobulin G antiendotoxin antibodies , 1987, Infection and immunity.

[33]  J. Whicher,et al.  AN Evaluation of the Hyland Laser Nephelometer PDQ System for the Measurement of Immunoglobulins , 1978, Annals of clinical biochemistry.

[34]  H. Kocher,et al.  Risk scoring in surgical patients. , 1999, The British journal of surgery.

[35]  T. Starzl,et al.  RISK FACTORS AsSOCIATED WITH MORTALITY AND INFECTIOUS MORBIDITY , 1998 .

[36]  M. Haller,et al.  Perioperative mucosal pH and splanchnic endotoxin concentration in orthotopic liver transplantation. , 1996, British journal of anaesthesia.

[37]  J. Hurley.  Endotoxemia and liver transplantation. , 1995, Critical care medicine.

[38]  D. V. van Thiel,et al.  Endotoxemia is associated with renal dysfunction in liver transplantation recipients during the first postoperative week. , 1995, Hepato-gastroenterology.

[39]  G. Barclay.  Endogenous endotoxin-core antibody (EndoCAb) as a marker of endotoxin exposure and a prognostic indicator: a review. , 1995, Progress in clinical and biological research.

[40]  D. V. van Thiel,et al.  Liver transplantation (1). , 1989, The New England journal of medicine.

[41]  L. Adinolfi,et al.  Endotoxemia in a series of 104 patients with chronic liver diseases: prevalence and significance. , 1982, Digestion.

[42]  T E Starzl,et al.  Liver transplantation. , 1967, Bulletin de la Societe internationale de chirurgie.