Impact of MELD allocation policy on survival outcomes after liver transplantation: a single-center study in northeast Brazil

OBJECTIVE: To analyze the impact of model for end-stage liver disease (MELD) allocation policy on survival outcomes after liver transplantation (LT). INTRODUCTION: Considering that an ideal system of grafts allocation should also ensure improved survival after transplantation, changes in allocation policies need to be evaluated in different contexts as an evolutionary process. METHODS: A retrospective cohort study was carried out among patients who underwent LT at the University of Pernambuco. Two groups of patients transplanted before and after the MELD allocation policy implementation were identified and compared using early postoperative mortality and post-LT survival as end-points. RESULTS: Overall, early postoperative mortality did not significantly differ between cohorts (16.43% vs. 8.14%; p = 0.112). Although at 6 and 36-months the difference between pre-vs. post-MELD survival was only marginally significant (p = 0.066 and p = 0.063; respectively), better short, medium and long-term post-LT survival were observed in the post-MELD period. Subgroups analysis showed special benefits to patients categorized as nonhepatocellular carcinoma (non-HCC) and moderate risk, as determined by MELD score (15-20). DISCUSSION: This study ensured a more robust estimate of how the MELD policy affected post-LT survival outcomes in Brazil and was the first to show significantly better survival after this new policy was implemented. Additionally, we explored some potential reasons for our divergent survival outcomes. CONCLUSION: Better survival outcomes were observed in this study after implementation of the MELD criterion, particularly amongst patients categorized as non-HCC and moderate risk by MELD scoring. Governmental involvement in organ transplantation was possibly the main reason for improved survival

Impact of MELD allocation policy on survival outcomes after liver transplantation: a single-center study in northeast Brazil

OBJECTIVE: To analyze the impact of model for end‐stage liver disease (MELD) allocation policy on survival outcomes after liver transplantation (LT). INTRODUCTION: Considering that an ideal system of grafts allocation should also ensure improved survival after transplantation, changes in allocation policies need to be evaluated in different contexts as an evolutionary process. METHODS: A retrospective cohort study was carried out among patients who underwent LT at the University of Pernambuco. Two groups of patients transplanted before and after the MELD allocation policy implementation were identified and compared using early postoperative mortality and post‐LT survival as end‐points. RESULTS: Overall, early postoperative mortality did not significantly differ between cohorts (16.43% vs. 8.14%; p = 0.112). Although at 6 and 36‐months the difference between pre‐ vs. post‐MELD survival was only marginally significant (p = 0.066 and p = 0.063; respectively), better short, medium and long‐term post‐LT survival were observed in the post‐MELD period. Subgroups analysis showed special benefits to patients categorized as non‐hepatocellular carcinoma (non‐HCC) and moderate risk, as determined by MELD score (15‐20). DISCUSSION: This study ensured a more robust estimate of how the MELD policy affected post‐LT survival outcomes in Brazil and was the first to show significantly better survival after this new policy was implemented. Additionally, we explored some potential reasons for our divergent survival outcomes. CONCLUSION: Better survival outcomes were observed in this study after implementation of the MELD criterion, particularly amongst patients categorized as non‐HCC and moderate risk by MELD scoring. Governmental involvement in organ transplantation was possibly the main reason for improved survival

Association between the colorimetry of the liver surface and the intensity of steatosis. Experimental study in rats subjected to steatogenic diet

Os enxertos hepáticos com esteatose apresentam risco aumentado para a disfunção e o não funcionamento primário. Entretanto, considerando o permanente desequilíbrio entre a oferta e a demanda de enxertos, justifica-se o uso de fígados esteatóticos com um risco aceitável. O padrão ouro para o diagnóstico do grau da esteatose hepática, na prática clínica, é o exame histológico. Entretanto, no cenário dos transplantes, a estimativa do grau de esteatose do enxerto hepático depende do exame macroscópico. Nesse procedimento a leitura da cor é realizada de forma subjetiva e a força da associação cor-esteatose não é conhecida. Considerando esses aspectos, a presente pesquisa teve como objetivo verificar a associação entre a cor do fígado e a intensidade da esteatose hepática, aferindo a cor do fígado, de forma precisa com um colorímetro e quantificando a esteatose com dois exames considerados de referência. Método: Ratos wistar, machos, foram divididos em quatro grupos de quinze animais. Os animais do grupo controle receberam dieta padrão. Os outros três grupos receberam dieta esteatogênica durante, respectivamente, dois, quatro e seis dias. Os ratos foram submetidos à laparotomia, biópsia hepática (pré e pós-perfusão do fígado) para realizar o exame histológico, colorimetria no padrão RGB (pré e pós-perfusão do fígado), conversão da cor, do padrão RGB, para o padrão CINZA, coleta de sangue para realizar exames laboratoriais e hepatectomia (para determinar o peso relativo do fígado e a extração da gordura). A análise estatística foi realizada com o pacote de software estatístico IBM SPSS Statistics 18, e o valor p < 0.05 foi considerado com significado estatístico. Resultados: Foi observada correlação positiva entre os percentuais de gordura e a intensidade das cores pré perfusão (coeficiente de correlação da cor vermelha 0,874, cor verde 0,747 e cor azul 0,763) e pós-perfusão (coeficiente de correlação da cor vermelha 0,900, cor verde 0,886 e cor azul 0,856). As medias dos valores da colorimetria, pré e pós perfusão, apresentaram diferença estatisticamente significativa (p < 0,001). A acurácia da colorimetria pós perfusão, determinada pela curva ROC, foi de100% na determinação da presença de esteatose, 96,2% para o grau moderado ou intenso e 80,4% para o grau intenso da esteatose. Foi verificada diferença significativa dos valores da colorimetria (p < 0,001) entre as medias dos diversos grupos com exceção entre os grupos concentração de gordura moderada X gordura intensa e entre os grupos graus histológicos da esteatose leve X moderada X intensa. Conclusões: a) A cor do fígado, pré e pós perfusão, apresentou correlação forte com a esteatose, de forma positiva e linear; b) A colorimetria, pré e pós perfusão, apresenta a mesma acurácia na identificação da esteatose c) A colorimetria apresentou acurácia perfeita na identificação da presença da esteatose e tendência para classificar, em um mesmo grupo, a esteatose moderada e intensa.Hepatic grafts with steatosis are at increased risk for dysfunction and primary non-functioning. However, considering the permanent imbalance between supply and demand of grafts, the use of specially selected livers with steatosis is justified. The gold standard for the diagnosis of hepatic steatosis in clinical practice is histological examination. However, in the transplant scenario, the estimation of the grade of hepatic graft steatosis depends on macroscopic examination. In this procedure the color reading is carried out subjectively and the strength of the association of color-steatosis is not known. Considering these aspects, the present study aimed to verify the association between liver color and liver steatosis intensity, accurately assessing the color of the liver with a colorimeter and quantifying steatosis with two exams considered as reference. Method: Male wistar rats were divided into four groups of fifteen animals. The animals in the control group received a standard diet. The other three groups received a steatogenic diet during, respectively, two, four and six days. Rats were submitted to laparotomy, liver biopsy (pre and post-perfusion of the liver) for conventional histological examination, colorimetry in the RGB pattern (pre and post-perfusion of the liver), color conversion from the RGB standard to the GRAY standard, Blood collection for laboratory tests and hepatectomy (to determine relative liver weight and fat extraction). Statistical analysis was performed with the statistical software package SPSS Statistics 18, and p value <0.05 was considered statistically significant. Results: A positive correlation was observed between fat percentages and preperfusion color intensity (red color correlation coefficient 0.874, green color 0.747 and blue color 0.763) and postperfusion (correlation coefficient of red color 0.900, green color 0.866 and blue color 0.856). The mean values of the colorimetry, pre- and post-perfusion, presented a statistically significant difference (p <0.001). The accuracy of the post-perfusion colorimetry, determined by the ROC curve, was 100% in the determination of the presence of steatosis, 96.2% for the moderate or intense degree and 80.4% for the intense degree of steatosis. There was a significant difference (p <0.001) between the means of the different groups except for the groups of moderate fat X intense fat concentration and between the histological grades groups of mild X intense moderate X steatosis. Conclusions: a) The color of the liver, pre and post perfusion, showed a strong correlation with steatosis, in a positive and linear way; B) Colorimetry, pre- and post-perfusion, shows the same accuracy in the identification of steatosis. C) Colorimetry showed perfect accuracy in the presence of steatosis and a tendency to classify moderate and severe steatosis in the same group

Association between the colorimetry of the liver surface and the intensity of steatosis. Experimental study in rats subjected to steatogenic diet

Os enxertos hepáticos com esteatose apresentam risco aumentado para a disfunção e o não funcionamento primário. Entretanto, considerando o permanente desequilíbrio entre a oferta e a demanda de enxertos, justifica-se o uso de fígados esteatóticos com um risco aceitável. O padrão ouro para o diagnóstico do grau da esteatose hepática, na prática clínica, é o exame histológico. Entretanto, no cenário dos transplantes, a estimativa do grau de esteatose do enxerto hepático depende do exame macroscópico. Nesse procedimento a leitura da cor é realizada de forma subjetiva e a força da associação cor-esteatose não é conhecida. Considerando esses aspectos, a presente pesquisa teve como objetivo verificar a associação entre a cor do fígado e a intensidade da esteatose hepática, aferindo a cor do fígado, de forma precisa com um colorímetro e quantificando a esteatose com dois exames considerados de referência. Método: Ratos wistar, machos, foram divididos em quatro grupos de quinze animais. Os animais do grupo controle receberam dieta padrão. Os outros três grupos receberam dieta esteatogênica durante, respectivamente, dois, quatro e seis dias. Os ratos foram submetidos à laparotomia, biópsia hepática (pré e pós-perfusão do fígado) para realizar o exame histológico, colorimetria no padrão RGB (pré e pós-perfusão do fígado), conversão da cor, do padrão RGB, para o padrão CINZA, coleta de sangue para realizar exames laboratoriais e hepatectomia (para determinar o peso relativo do fígado e a extração da gordura). A análise estatística foi realizada com o pacote de software estatístico IBM SPSS Statistics 18, e o valor p < 0.05 foi considerado com significado estatístico. Resultados: Foi observada correlação positiva entre os percentuais de gordura e a intensidade das cores pré perfusão (coeficiente de correlação da cor vermelha 0,874, cor verde 0,747 e cor azul 0,763) e pós-perfusão (coeficiente de correlação da cor vermelha 0,900, cor verde 0,886 e cor azul 0,856). As medias dos valores da colorimetria, pré e pós perfusão, apresentaram diferença estatisticamente significativa (p < 0,001). A acurácia da colorimetria pós perfusão, determinada pela curva ROC, foi de100% na determinação da presença de esteatose, 96,2% para o grau moderado ou intenso e 80,4% para o grau intenso da esteatose. Foi verificada diferença significativa dos valores da colorimetria (p < 0,001) entre as medias dos diversos grupos com exceção entre os grupos concentração de gordura moderada X gordura intensa e entre os grupos graus histológicos da esteatose leve X moderada X intensa. Conclusões: a) A cor do fígado, pré e pós perfusão, apresentou correlação forte com a esteatose, de forma positiva e linear; b) A colorimetria, pré e pós perfusão, apresenta a mesma acurácia na identificação da esteatose c) A colorimetria apresentou acurácia perfeita na identificação da presença da esteatose e tendência para classificar, em um mesmo grupo, a esteatose moderada e intensa.Hepatic grafts with steatosis are at increased risk for dysfunction and primary non-functioning. However, considering the permanent imbalance between supply and demand of grafts, the use of specially selected livers with steatosis is justified. The gold standard for the diagnosis of hepatic steatosis in clinical practice is histological examination. However, in the transplant scenario, the estimation of the grade of hepatic graft steatosis depends on macroscopic examination. In this procedure the color reading is carried out subjectively and the strength of the association of color-steatosis is not known. Considering these aspects, the present study aimed to verify the association between liver color and liver steatosis intensity, accurately assessing the color of the liver with a colorimeter and quantifying steatosis with two exams considered as reference. Method: Male wistar rats were divided into four groups of fifteen animals. The animals in the control group received a standard diet. The other three groups received a steatogenic diet during, respectively, two, four and six days. Rats were submitted to laparotomy, liver biopsy (pre and post-perfusion of the liver) for conventional histological examination, colorimetry in the RGB pattern (pre and post-perfusion of the liver), color conversion from the RGB standard to the GRAY standard, Blood collection for laboratory tests and hepatectomy (to determine relative liver weight and fat extraction). Statistical analysis was performed with the statistical software package SPSS Statistics 18, and p value <0.05 was considered statistically significant. Results: A positive correlation was observed between fat percentages and preperfusion color intensity (red color correlation coefficient 0.874, green color 0.747 and blue color 0.763) and postperfusion (correlation coefficient of red color 0.900, green color 0.866 and blue color 0.856). The mean values of the colorimetry, pre- and post-perfusion, presented a statistically significant difference (p <0.001). The accuracy of the post-perfusion colorimetry, determined by the ROC curve, was 100% in the determination of the presence of steatosis, 96.2% for the moderate or intense degree and 80.4% for the intense degree of steatosis. There was a significant difference (p <0.001) between the means of the different groups except for the groups of moderate fat X intense fat concentration and between the histological grades groups of mild X intense moderate X steatosis. Conclusions: a) The color of the liver, pre and post perfusion, showed a strong correlation with steatosis, in a positive and linear way; B) Colorimetry, pre- and post-perfusion, shows the same accuracy in the identification of steatosis. C) Colorimetry showed perfect accuracy in the presence of steatosis and a tendency to classify moderate and severe steatosis in the same group

Postoperative kidney injury does not decrease survival after liver transplantation Insuficiência renal pós-operatória não diminui a sobrevivência após transplante hepático

PURPOSE: To explore the effect of acute kidney injury (AKI) on long-term survival after conventional orthotopic liver transplantation (OLT) without venovenous bypass (VVB). METHODS: A retrospective cohort study was carried out on 153 patients with end-stage liver diseases transplanted by the Department of General Surgery and Liver Transplantation of the University of Pernambuco, from August, 1999 to December, 2009. The Kaplan-Meier survival estimates and log-rank test were applied to explore the association between AKI and long-term patient survival, and multivariate analyses were applied to control the effect of other variables. RESULTS: Over the 12.8-year follow-up, 58.8% patients were alive with a median follow-up of 4.5-year. Patient 1-, 2-, 3- and 5-year survival were 74.5%, 70.6%, 67.9% and 60.1%; respectively. Early postoperative mortality was poorer amongst patients who developed AKI (5.4% vs. 20%, p=0.010), but long-term 5-year survival did not significantly differed between groups (51.4% vs. 65.3%; p=0.077). After multivariate analyses, AKI was not significantly related to long-term survival and only the intraoperative transfusion of red blood cells was significantly related to this outcome (non-adjusted Exp[b]=1.072; p=0.045). CONCLUSION: The occurrence of postoperative acute kidney injury did not independently decrease patient survival after orthotopic liver transplantation without venovenous bypass in this data from northeast Brazil.<br>OBJETIVO: Explorar o efeito da insuficiência renal aguda (IRA) na sobrevivência de longo prazo após o transplante hepático convencional ortotópico (THC) sem desvio venovenoso (DVV). MÉTODOS: Estudo de coorte retrospectivo envolvendo153 pacientes portadores de doença hepática terminal transplantados pelo Departamento de Cirurgia Geral e Transplante Hepático da Universidade de Pernambuco, no período de agosto de 1999 a dezembro de 2009. O método de Kaplan-Meier e o teste log-rank foram aplicados para explorar a associação entre o IRA com a sobrevivência de longo prazo dos pacientes, aplicando-se o modelo multivariado de riscos proporcionais de Cox para controlar o efeito de outras variáveis. RESULTADOS: A proservação atingiu 12,8 anos, durante a qual 58,8% dos pacientes permaneceram vivos com mediana de acompanhamento de 4,5 anos. As taxas de sobrevivência cumulativa de 1 -, 2 -, 3 - e 5 anos foram de 74,5%, 70,6%, 67,9% e 60,1%; respectivamente. A taxa de mortalidade pós-operatória precoce foi maior entre os pacientes que desenvolveram IRA (5,4% vs. 20%, p = 0,010), mas a sobrevivência de longoprazoem5 anos não diferiu significativamente entre os grupos (51,4% vs. 65,3%, p = 0,077). Após análise multivariada, a IRA nãofoisignificativamenterelacionado à sobrevivência a longo prazo e apenas transfusão intra-operatório de hemácias foi significativamente relacionado com este desfecho (Exp [b] não-ajustado = 1,072, p = 0,045). CONCLUSÃO: A ocorrência de insuficiência renal aguda pós-operatória não diminuiu de forma independente a sobrevivência dos pacientes após transplante hepático convencional sem desvio venovenoso nesta casuística do nordeste do Brasileiro