Liver :: Lessons learned from liver retransplantation

A new study on liver retransplantation (re-LT) over a 15 year period at a clinic in Germany found that indications for the surgery had changed and there were fewer rejections, complications, and recurrence of disease during that time.

The positive trend may be due to improvements in intensive care management and immunosuppressants, along with early decisions about when to retransplant despite the shortage of quality donor organs.

While liver transplantation has become increasingly successful over the last two decades, liver retransplantation shows significantly inferior results. The reasons for this include infections following surgery, multiorgan failure, bleeding complications, recurrence of the underlying disease, and chronic rejections. In addition, it is more expensive than first-time transplants and presents the problem of claiming organs that might have otherwise been used by first-time recipients, who are more likely to have a better outcome. For these reasons, retransplantation is controversial, but for many patients it is the only alternative to death.

Led by Robert Pfitzmann, M.D. of Charit? Virchow Clinic in Berlin, Germany, researchers conducted a study of 119 retransplant recipients in their clinic between 1989 and 2003 in order to find ways of improving treatment and results. Indications for retransplant included initial non-function of a transplanted liver, recurrence of the underlying disease, rejection, blood clots in the main artery that carries blood to the liver, and ischemic-type-biliary-lesions (ITBL), a complication of liver transplants. The mean follow-up was approximately 5 years; 65 percent of retransplants were performed within the first year of the initial transplant, the vast majority taking place within three months.

Analysis showed that coma, hemoglobin and the amount of plasma transfused during surgery were independent predictors of survival following retransplantation. In contrast to other studies, creatinine (a protein in the blood), the amount and time between the first and second transplant, donor and recipient age, ischemia time, bilirubin and hepatitis C status did not influence survival. “These results support our assumption that the recipients’ clinical status immediately before re-LT plays a very important role on the outcome of our patients, whereas the donor status appears less important” the authors note. At the same time, they acknowledge that they used “high quality standard selection criteria and acceptance of donor organs,” which may explain why donor status was not predictive of outcome.

Their findings led to several therapeutic measures, including lowering the dosage of immunosuppressants very early, administering medication to improve kidney function, early blood transfusions, and continuous improvements in intensive care management. They note that patient survival after retransplant very strongly depends on the reason for the transplant, with patients experiencing ITBL and rejection showing the best survival rates. They also observed that the major complications leading to death following retransplant were bacterial infections with septic complications, which indicates a variety of measures that can be undertaken to prevent infection from claiming lives. Although they achieved good results, they conclude that “further progress and improvement in the treatment of retransplanted patients is required to enchance survival after re-LT.”

In an accompanying editorial in the same issue, R. Mark Ghobrial, M.D., Ph.D., F.R.C.S. of the David Geffen School of Medicine at University of California Los Angeles noted that retransplantation requires sophisticated decision-making but that accurate outcome predictors are lacking. The author suggests that the most important contribution of the current study is the determination of factors that predict outcomes in retransplants, noting that it is in agreement with previous reports stressing the influence of recipient status on retransplant outcome. However, he states that while the study minimizes the importance of donor status, these effects should not be underestimated. He questions why factors found to be independent predictors of death at other hospitals were not significant in the current study, noting that it may be due to the level of surgical expertise or the ability of the current study’s authors to apply stringent selection criteria for donors and recipients. “The fruits of this selection effort are reflected in the good survival achieved in this series,” he concludes. “The lessons for re-OLT may therefore be: selection, selection, selection.”

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