The Analysis of Prognostic Factors Affecting Survival in Liver Transplantation: A Single Institution Experience

Sung Won Park; Gil Jae Lee; Sang Tae Choi; Yeon Ho Park; Jung Nam Lee; Keon Kuk Kim

doi:10.4285/jkstn.2014.28.4.211

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Park, Lee, Choi, Park, Lee, and Kim: The Analysis of Prognostic Factors Affecting Survival in Liver Transplantation: A Single Institution Experience

Original Article

J Korean Soc Transplant 2014;28(4):211-218.

Published online: 10 January 2014

DOI: https://doi.org/10.4285/jkstn.2014.28.4.211

The Analysis of Prognostic Factors Affecting Survival in Liver Transplantation: A Single Institution Experience

Sung Won Park, M.D., Gil Jae Lee, M.D., Sang Tae Choi, M.D., Yeon Ho Park, M.D., Jung Nam Lee, M.D., Keon Kuk Kim, M.D.

Department of Surgery, Gachon University Gil Medical Center, Gachon Graduate School of Medicine, Incheon, Korea

Corresponding author: Keon Kuk Kim Department of Surgery, Gachon University Gil Medical Center, Gachon Graduate School of Medicine, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 405-760, Korea Tel: 82-32-460-3244, Fax: 82-32-460-3247 E-mail: kimkk@gilhospital.com

Received 14 July 2014 Revised 14 November 2014 Accepted 18 November 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Liver transplantation is considered as the most powerful modality for patients with acute on chronic liver failure and fulminant hepatic failure. The aim of this study is to identify potential prognostic factors that may affect survival after emergent liver transplantation.

Methods

A total of 42 patients who underwent emergent liver transplantation at Gachon University Gil Medical Center from June 2005 to May 2013 were enrolled. The clinical scoring system analyzed for this study were as follows: Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), Model for end-stage liver disease with incorporation of serum sodium (MELD-Na), Acute physiology and chronic health evaluation II (APACHE II), and Sequential Organ Failure Assessment (SOFA).

Results

Preoperative SOFA and APACHE scores were closely related with patient's survival after the operation. Also, the changed value of SOFA while patients waited for their transplantation showed to be significant. In a univariate analysis, serum bilirubin and Glasgow Coma Scale (GCS) showed statistical significance for patient's prognosis. Several factors, such as the use of mechanical ventilator and inotropic agent for treating multiple organ failure were also important. The central nervous system and cardiovascular scores showed an intimate relation with the survival group by a more detailed analysis in SOFA. In a multivariate analysis, SOFA and bilirubin levels affected patient's survival.

Conclusions

In emergent liver transplantation with acute on chronic liver failure and fulminant liver failure, recipient's hepatic function is an important factor along with the donated liver condition l eading to successful operation. Also, it is important to pay attention to the progression of organ failure in predicting the prognosis.

Keywords: Liver transplantation, Prognostic factor, Organ failure

References

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Fig. 1.

Receiver operating characteristic (ROC) curves for pre-operative Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), model for end-stage liver disease with incorporation of serum sodium (MELD-Na), Sequential Organ Failure Assessment (SOFA), and Acute Physiology And Chronic Health Evaluation II (APACHE) II scoring system. Each value marked at Table 6.

Table 1.

Demographic and clinical data of total patients

Variable	All (n=42)
Age (yr; mean±SD)	46.9±11.9 (14∼69)
Sex (male/female)	27/15
Etiology
HBV	23 (55)
Alcohol	8 (19)
Fulminant liver failure	8 (19)
Other	3 (7)
Type of donor
Living	6 (14)
Deceased	36 (86)
Waiting time for operation (day)	9.2±12.0
Medical condition
HEP grade (I, II/III, IV)	18/24 (43/57)
Inotropic agent (yes/no)	7/35 (17/83)
Ventilator (yes/no)	8/34 (19/81)
Hemodialysis (yes/no)	8/34 (19/81)
Scoring system
CTP	12±1
MELD	34±9
MELD-Na	35±7
SOFA	9±3
APACHE II	18±7
Data are presented as mean±SD or number (%).

Abbreviations: HEP, hepatic encephalopathy; CTP, Child-Turcotte-Pugh; MELD, model for end-stage liver disease; MELD-Na, model for end-stage liver disease with incorporation of serum sodium; SOFA, Sequential Organ Failure Assessment; APACHE II, Acute Physiology And Chronic Health Evaluation II.

Table 2.

Comparison of demographic and clinical data between survivor and nonsurvivor

Variable	Survivor (n=26)	Nonsurvivor (n=16)	P-value
General
Sex (male/female)	17/9	10/6	0.850
Age	46.3±11.5	47.8±12.8	0.872
Cause			0.363
HBV	16 (62)	7 (44)
Alcohol	5 (19)	3 (9)
Fulminant	3 (11)	5 (31)
Other	2 (8)	1 (6)
Type of donor			0.517
Deceased	23 (88)	13 (81)
Living	3 (12)	3 (19)
Waiting time (day)	10.5±13.0	7.1±10.2	0.373
Clinical factor
GCS	12±4	9±5	0.023
BT (^o C)	36.7±0.4	36.9±0.7	0.254
MAP (mmHg)	83±18	75±18	0.134
HR	85±20	98±25	0.057
RR	20±4	21±6	0.548
Biochemical factor
pH	7.4±0.1	7.4±0.1	0.837
Albumin (g/dL)	2.9±0.5	2.8±0.4	0.647
Bilirubin (mg/dL)	26.3±14.6	17.6±10.3	0.043
Prothrombin time (INR)	3.3±1.4	3.1±1.1	0.625
Creatinine (mg/dL)	1.5±1.6	2.3±2.2	0.170
Sodium (mEq/L)	134±11	136±6	0.538
Platelet (×10³/mm³)	119.0±106.3	73.4±42.9	0.060
Medical condition
HEP (grade I, II/III, IV)	14/12	4/12	0.067
Ventilator (yes/no)	2/24	6/10	0.017
Inotropic (yes/no)	2/24	5/11	0.047
Hemodialysis (yes/no)	4/22	4/12	0.441

Data are presented as mean±SD or number (%).

Abbreviations: HBV, hepatitis B virus; GCS, Glasgow Coma Scale; BT, body temperature; MAP, mean arterial pressure; HR, heart rate; RR, respiration rate; HEP, hepatic encephalopathy.

Table 3.

Variables of scores of the patients according to survival

Variable	Preoperative score			Changed valuefor waiting operation
Variable	Survival (n=26)	Death (n=16)	P-value	Δ Survival ^a	Δ Death ^a	P-value
CTP	12.2±1.4	12.3±1.4	0.790	0.4±1.5	0.6±0.9	0.739
MELD	33.5±8.8	33.8±8.4	0.939	2.9±6.3	2.5±5.3	0.823
MELD-Na	35.1±7.2	34.7±7.4	0.868	2.5±5.5	1.8±4.8	0.671
SOFA	7.9±2.7	10.7±3.6	0.007	0.7±2.4	2.8±3.2	0.025
APACHE II	16.1±6.2	21.4±7.9	0.020	2.0±6.7	3.9±8.4	0.431

Data are presented as mean±SD.

Abbreviations: CTP, Child-Turcotte-Pugh; MELD, model for end-stage liver disease; MELD-Na, model for end-stage liver disease with incorporation of serum sodium; SOFA, Sequential Organ Failure Assessment; APACHE II, Acute Physiology And Chronic Health Evaluation II.

^a Δ, changed value for waiting time of operation.

Table 4.

Analysis of combined organ failure in Sequential Organ Failure Assessment

MOF variable	Survival		Death		P-value
MOF variable	＜3	3∼4	＜3	3∼4	P-value
Respiratory		0		0	–
CNS	20	6	6	10	0.011
Cardiovascular	25	1	11	5	0.014
Hepatic	3	23	2	14	0.283
Hematologic	18	8	9	7	0.394
Renal	23	3	13	3	0.517

Abbreviations: MOF, multiple organ failure; CNS, central nervous system.

Table 5.

Multivariate logistic regression of predictive factors according to survival

Variable	HR	95% CI	P-value
SOFA, ＜8.5	0.69	0.53∼0.91	0.008
Bilirubin, ≥14.7	1.08	1.01∼1.16	0.022

Abbreviations: HR, hazard ratio; CI confidence interval; SOFA, Sequential Organ Failure Assessment.

Table 6.

Predictive accuracy for transplantation

Variable	Cutoff value	Sensitivity	Specificity	PPV	NPV	AUC
SOFA	8.5	0.69	0.69	0.58	0.78	0.73
APACHE II	15.5	0.75	0.54	0.50	0.78	0.69

Abbreviations: PPV, positive predictive value; NPV, negative predictive value; AUC, area under the curve; SOFA, Sequential Organ Failure Assessment; APACHE II, Acute Physiology And Chronic Health Evaluation II.

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