An analysis of multidimensional factors and outcomes for liver transplantation in single center of Taiwan
Date Issued
2014
Date
2014
Author(s)
Hsieh, Chung-Bao
Abstract
Background: Liver transplantation (LT) becomes the final therapeutic choice for end-stage liver disease or hepatocellular carcinoma. In Taiwan, living-related donor liver transplantation (LDLT) is an alternative and become popular owe to the shortage of cadaveric donor. The outcome of LT has been studied and discussed worldwide, either monitor the quality of medical care from internally; or being the guideline of monitor by the press or government from externally. Both of them could affect the health care system. Recent outcome studies were focused on risk factors of liver recipients, such as cormorbilities, the degree of liver cirrhosis, or patients with hepatocellular carcinoma whose tumor number and size, were influent the clinical outcome. However, LT is a very elaborate surgery comprising both the donor and recipient parts. The risk factors of liver donor, the matched factors between donor and recipient: e.g. Graft recipient weight ratio (GRWR), gender matched factor, age matched factor, are also influent the clinical outcomes. Besides, the experience and refinement techniques of transplant surgeon, the medication after liver transplant, the rejection episode, the infection disease e.g. T.B. or CMV infected and De Novo cancer were affect the clinical outcomes of LT. Nowadays, there are no any studies have contained all dimensions and clarified the interaction between each risk factors. The statistics method which used in the previous risk factor studied could not analysis the surgeon and team learning curve, donor-recipient matched factors and non-linear variables. The purpose of this study is tried to define the risk factors to influent the clinical outcomes of LT from all dimensions aformentioned. Materials and Methods: In this retrospective study, we collected the data of donor, recipient, donor and recipient matched variables, transplant surgeon related factors, and post transplant related factors and determined the risk factors of clinical outcomes of liver transplant from single medical center. The clinical outcomes were defined as the post-transplant neurological complications, post-transplant biliary complications, and the early mortality in 30 days & 90 days after transplant, and overall mortality. A total of 295 patients undergoing LT at Tri-Service General Hospital were enrolled. The collected data were analyzed using the R statistic software to fit the logistic regression analysis and Cox’s regression analysis to figure out the linear factors. Non-linear factors were examined to fit the generalized additive models (GAM).All the factors were used for the multiple variables analysis and to determine the risk factors to influent the clinical outcomes of LT. Result: The risk factors for post-transplant neurological complications were: dimension of recipient included age <29 or >60 y/o, body mass index (BMI) <21.6 or >27.6 kg/m2, high Child-Pugh score while transplant, positive hepatic coma history, positive psychiatry disease history, negative of varices bleeding history, higher FK level in post-transplant 7 days, positive of intra-abdominal infection (IAI); the dimension of donor is donor’s age <22 or >40 y/o; the dimension of donor-recipient matched included male to male matched, graft recipient weight ratio (GRWR) between 0.9% to 1.9%; the dimension of transplant surgeon is learning curve within first 31 case. The area under curve of this statistic model was 0.855. The risk factors for post-transplant biliary complications included dimension of recipient included Child-Pugh score between 7 to 11, Carlson index between 4 to 6 , the ammonia level <70 mg/dl in transplant, the higher serum creatinine level in transplant, the higher serum albumin level in transplant; the dimension of donor-recipient matched included the GRWR and Child score ratio <0.08 or >0.2, GRWR and MELD score ratio <0.08 or >0.2, donor age cross recipient age >2000; the dimension of operation included blood loss >2800 ml, partial graft and right lobe graft; the dimension of surgeon included learning curve within first 90 case and surgeon A; the dimension of post-transplant complications included post-transplantation acute rejection episode, post-transplant hemodialysis (PTHD); the dimension of external environment is team reorganization after 2008-may. The concordance of this statistic model is 0.806. The risk factors for mortality within 30 days after transplant included: in the dimension of recipient is MELD score > 28; in the dimension of donor-recipient matched is female donate to female; in the dimension of operation is larger blood loss volume; in the dimension of post-transplant complication is the primary non-function of graft (PNF). The area under curve of this statistic model was 0.961. The risk factors of mortality within 90 days after transplant included (1) recipient factor: MELD score > 28 and the serum glucose level > 145 mg/dL while transplant, (2) donor factor: <18 or >26y/o; in the dimension of donor-recipient matched included female donate to female and GRWR<0.9% or >1.8%; (3) operation factor: longer operation time; in the dimension of post-transplant complication are the PNF, the lower FK level in post op 7 day <3.6ng/dl, in hospital complications Clavien grade >= IIIA; (4) surgeon factor: transplant team performed sequence number between 121th and 246th. The area under curve of this statistic model is 0.962. The risk factors of long term mortality in recipient included (1) recipient-related factor: age <39 or >56y/o, positive history of alcohol drinking, negative history of varices bleeding , MELD score > 28 ,and BMI <20.8 or >32.3 kg/m2; (2) donor-recipient matched factor: female donate to male and GRWR<0.8 % or >1.6% ; in dimension of operation is longer operation time; (3) surgeon factor: learning curve within first 50 case; in the dimension of post-transplant complications are included PTHD, IAI, PNF, abnormal serum sodium level in POD7, DE NOVO cancer, the tuberculosis infection, and acute rejection. The concordance of this statistic model was 0.890. Conclusion The risk factors associated with the clinical outcomes of LT are multiple dimensions and multi-factories. After controlling the risk factors of dimensions included donor, recipient, donor-recipient match, and post operation; the learning curve of transplant team & surgeon will affect the overall mortality and post-transplant neurologic complications, biliary complication; but not influent the post transplant early mortality. Contribution The present study clarified multiple dimensions that affected the clinic outcomes of LT with ignorance. The results of this study provided information that helps surgeons perform better decision-making, avoid the risk factors and improve the clinical outcomes of LT after surgery. Besides, this study is first study applying R analysis technique to investigate clustered data which was neglected in the past outcome studies in the LT setting. The results of this study encourage the hospital manager to emphasis not only the recipient and donor factors, but also the well-planned training protocol to increment the maturity of transplant team and improve the experience of transplant surgeon.
Subjects
liver transplantation (LT)
donor-recipient matched factor
transplant surgeon and team accumulated number
learning curve
post-transplant biliary complication
post-transplant neurologic complication
early mortality after transplant
long-term survival
risk factors
multivariate regression analysis
non-linear factor analysis
SDGs
Type
thesis
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