Outcomes of adult living donor liver transplantation: comparison of the Adult-to-adult Living Donor Liver Transplantation Cohort Study and the national experience

Abstract

The study objectives were to determine whether the findings of the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) reflect the U.S. national experience and to define risk factors for patient mortality and graft loss in living donor liver transplantation (LDLT). A2ALL previously identified risk factors for mortality after LDLT, which included early center experience, older recipient age, and longer cold ischemia time. LDLT procedures at 9 A2ALL centers (n = 702) and 67 non-A2ALL centers (n = 1664) from January 1998 through December 2007 in the Scientific Registry of Transplant Recipients database were analyzed. Potential predictors of time from transplantation to death or graft failure were tested using Cox regression. No significant difference in overall mortality between A2ALL and non-A2ALL centers was found. Higher hazard ratios (HRs) were associated with donor age (HR = 1.13 per 10 years, P = 0.0002), recipient age (HR = 1.20 per 10 years, P = 0.0003), serum creatinine levels (HR = 1.52 per loge unit increase, P < 0.0001), hepatocellular carcinoma (HR = 2.12, P<0.0001) or hepatitis C virus (HR = 1.18, P = 0.026), intensive care unit stay (HR = 2.52, P< 0.0001) or hospitalization (HR = 1.62, P < 0.0001) versus home, earlier center experience (LDLT case number 15: HR = 1.61, P < 0.0001, and a cold ischemia time >4.5 hours (HR = 1.79, P = 0.0006). Except for center experience, risk factor effects between A2ALL and non-A2ALL centers were not significantly different. Variables associated with graft loss were identified and showed similar trends. In conclusion, mortality and graft loss risk factors were similar in A2ALL and non-A2ALL centers. These analyses demonstrate that findings from the A2ALL consortium are relevant to other centers in the U.S. performing LDLT, and conclusions and recommendations from A2ALL may help to guide clinical decision making.

Figure 1

Figure 1a. Year of first living donor liver transplant (LDLT) in A2ALL (n=9) and non-A2ALL (n=67) centers. Figure 1b. Percent of LDLTs performed by year between 1998 and 2007 in A2ALL and non-A2ALL centers. Figure 1c. Number of LDLTs performed by year between 1998 and 2007 in A2ALL and non-A2ALL centers.

Figure 1

Figure 1a. Year of first living donor liver transplant (LDLT) in A2ALL (n=9) and non-A2ALL (n=67) centers. Figure 1b. Percent of LDLTs performed by year between 1998 and 2007 in A2ALL and non-A2ALL centers. Figure 1c. Number of LDLTs performed by year between 1998 and 2007 in A2ALL and non-A2ALL centers.

Figure 1

Figure 1a. Year of first living donor liver transplant (LDLT) in A2ALL (n=9) and non-A2ALL (n=67) centers. Figure 1b. Percent of LDLTs performed by year between 1998 and 2007 in A2ALL and non-A2ALL centers. Figure 1c. Number of LDLTs performed by year between 1998 and 2007 in A2ALL and non-A2ALL centers.

Figure 2

Relative risk of (a) patient mortality or (b) graft failure by center LDLT case number (Dashed line: A2ALL, Solid line: Non-A2ALL). Reference category: non-A2ALL center with case number >30. Adjusted for recipient and donor age, HCC and HCV diagnoses, creatinine, and medical condition at transplant; the graft failure model was also adjusted for recipient weight.

Figure 2

Relative risk of (a) patient mortality or (b) graft failure by center LDLT case number (Dashed line: A2ALL, Solid line: Non-A2ALL). Reference category: non-A2ALL center with case number >30. Adjusted for recipient and donor age, HCC and HCV diagnoses, creatinine, and medical condition at transplant; the graft failure model was also adjusted for recipient weight.

Figure 3

(a) Patient survival or (b) graft survival by center type and case number from an adjusted model, plotted for the mean covariate values of recipient (50) and donor age (37) at transplant, HCC (0.07) and HCV (0.37) diagnoses, creatinine (−0.09), and medical condition (ICU=0.04, hospitalized=0.12). The graft survival model was also adjusted for recipient weight (77 kg).

Figure 3

(a) Patient survival or (b) graft survival by center type and case number from an adjusted model, plotted for the mean covariate values of recipient (50) and donor age (37) at transplant, HCC (0.07) and HCV (0.37) diagnoses, creatinine (−0.09), and medical condition (ICU=0.04, hospitalized=0.12). The graft survival model was also adjusted for recipient weight (77 kg).