Liver transplantation for fulminant hepatic failure: experience with more than 200 patients over a 17-year period

Abstract

Objective: To analyze outcomes after liver transplantation (LT) in patients with fulminant hepatic failure (FHF) with emphasis on pretransplant variables that can potentially help predict posttransplant outcome.

Summary background data: FHF is a formidable clinical problem associated with a high mortality rate. While LT is the treatment of choice for irreversible FHF, few investigations have examined pretransplant variables that can potentially predict outcome after LT.

Methods: A retrospective review was undertaken of all patients undergoing LT for FHF at a single transplant center. The median follow-up was 41 months. Thirty-five variables were analyzed by univariate and multivariate analysis to determine their impact on patient and graft survival.

Results: Two hundred four patients (60% female, median age 20.2 years) required urgent LT for FHF. Before LT, the majority of patients were comatose (76%), on hemodialysis (16%), and ICU-bound. The 1- and 5-year survival rates were 73% and 67% (patient) and 63% and 57% (graft). The primary cause of patient death was sepsis, and the primary cause of graft failure was primary graft nonfunction. Univariate analysis of pre-LT variables revealed that 19 variables predicted survival. From these results, multivariate analysis determined that the serum creatinine was the single most important prognosticator of patient survival.

Conclusions: This study, representing one of the largest published series on LT for FHF, demonstrates a long-term survival of nearly 70% and develops a clinically applicable and readily measurable set of pretransplant factors that determine posttransplant outcome.

Figure 1. Transplants per year.

Figure 2. Etiology of acute liver failure.

Figure 3. Overall patient survival.

Figure 4. Causes of death.

Figure 5. Overall graft survival.

Figure 6. Cause of graft loss.

Figure 7. Group 1: Creatinine <1.45 mg/dL and time Jaundice to encephalopathy >3.5 days and INR >2.48; Group 2: Creatinine <1.45 mg/dL and time Jaundice to encephalopathy >3.5 days and INR <2.48; Group 3: Creatinine <1.45 mg/dL and time Jaundice to encephalopathy <3.5 days; Group 4: Creatinine >1.45 mg/dL regardless of other 2 values. P < 0.0001.

Figure 8. Group 1: Conjugated Bilirubin >11.95 and creatinine <1.45 and donor age <23.05; Group 2: Conjugated Bilirubin >11.95 and creatinine <1.45 and donor age >23.05; Group 3: Conjugated Bilirubin >5.65 and <11.95 and creatinine <1.45; Group 4: Conjugated Bilirubin >5.65 and creatinine >1.45; Group 5: Conjugated Bilirubin <5.65. P = 0.0005.