Early postoperative deaths of recipients after deceased donor liver transplantation

Hellenic Journal of Surgery 86

Early Postoperative Deaths of Recipients after Deceased Donor Liver TransplantationArunkumar Krishnan, Vimalraj Velayutham, Arulselvan Velusamy, Jayanthi Venkataraman

Hellenic Journal of Surgery (2014) 86:2, 83-87

Arunkumar Krishnan, Vimalraj Velayutham, Arulselvan Velusamy, Jayanthi VenkataramanDepartment of Gastroenterology and Liver Transplantation, Stanley Medical College Hospital, Chennai, India

Corresponding author: Dr. Arunkumar Krishnan, C-137, Karthikeyan Salai, Periyar Nagar, Perambur, Chennai-600082, IndiaE-mail: [email protected]

Received 20 Nov 2013; Accepted 22 Feb 2014

CLINICAL STUDY

Abstract

Aim-Background: Liver transplant often results in haemodynamic and biochemical changes in the immediate postoperative period, often causing concern to the treating physician.

The aim of the present study is to determine the preoperative clinical profile, along with the haematological and biochemical changes following deceased donor liver transplantation (DDLT) in the immediate 7-day postoperative period.

Method: A detailed assessment of the patients preoperative clinical diagnosis, presence of co-morbid illness and postoperative haematological, biochemical, and clinical events was made between survivors and those who died. Various parameters were compared between two groups to help us understand the variants that determined the early postoperative outcome in DDLT patients.

Results: A total of 26 patients were categorized into two groups: 18 patients were allocated to Group 1 (survivors) and 8 patients to Group 2 (mortality). There was no difference in the fluctuation of haemoglobin levels between the two groups. Early leukocytosis and persistent azotemia predicted early morbidity and mortality. A significant fall of platelet count predicted mortality. Transaminases showed a significant increase between the 2nd and 3rd postoperative day, after which they stabilised and showed a downwards trend by the 7th to 9th postoperative day in both groups. Intraoperative events like cardiac arrhythmias, ischaemic cardiac events, pulmonary thromboembolism, hepatic artery thrombosis, sepsis and multiorgan failure rank among the causes of death.

Conclusion: Preoperative co-morbid illness, postoperative worsening azotemia, persistent leukocytosis, and sepsis and cardiac events in the immediate postoperative period are factors that appear to predict the outcome post DDLT.

Key words: DDLT; early postoperative deaths; liver transplant

majority of deaths occur within the first weeks of liver transplantation. [2,5,6]

Predicting the outcome soon after liver transplantation remains indefinable, while anticipating the result of a proce-dure is essential and particularly persuasive in lifesaving organ transplantation. However, LT often results in haemodynamic and biochemical changes in the immediate postoperative period, often a cause of concern for the treating physician. The aim of the present study was to examine the preoperative clinical profile, the haematological and biochemical changes in the immediate 7-day postoperative period following de-ceased donor liver transplantation (DDLT).

Patients and Methods

From January 2006 to May 2010, 26 adult patients underwent liver transplantation at the Department of Gas-troenterology and Liver Transplantation, Stanley Medical College, all of whom were enrolled in the study. All the grafts were obtained from brain dead donors. A detailed assessment of the patients preoperative clinical diagnosis,

Introduction:

Liver transplantation (LT) is currently the only definite treatment of acute liver failure and chronic end-stage liver diseases. Despite the improvement in survival due to ma-jor advances in organ preservation, immunosuppressive agents and refinement of surgical techniques, there are still significant complications and mortality associated with LT. [1] Postoperative management and monitoring of potential complications in the early postoperative pe-riod play a critical role in the success of transplantation. [2-4] Improvements in this field have been a vital element in improving post-transplant survival. Nonetheless, the

84 Arunkumar Krishnan et al


Results

Twenty-four of the 26 adult liver transplant recipients were male, and two were female. The mean age of the recipients was 41.3 years (range 30-50yrs). All patients received organs from deceased donor sources. The primary diagnoses of these patients included cryptogenic cirrhosis (n=13), autoimmune cirrhosis (n=2), alcoholic cirrhosis (n=3) biliary cirrhosis (n=1), hepatitis B related cirrhosis (n=3), hepatitis C related cirrhosis (n=2), hepatocellular car-cinoma (n= 1), and Budd Chari syndrome (n=1). Eighteen patients were categorized as Group 1 (survivors) and eight patients as Group 2 (mortality). There was no difference in the fluctuation of haemoglobin levels between the two groups (10±4%).

Table 1 shows the postoperative clinical characteristics of both groups. There was no difference in the fluctuation of haemoglobin levels between the two groups (10±4%). Early leucocytosis secondary to infections was an important

presence of co-morbid illness and postoperative haemato-logical, biochemical, microbiological and clinical events was made among survivors (Group 1) and those who died (Group 2). Various haematological and clinical parameters were compared between the two groups to help us under-stand the variants that determined the early postoperative outcome in DDLT patients.

The study was approved by the Ethical Committee of the institution.

Statistical method

SPSS 17.0 version statistical software was used for statistical analysis and p value <0.05 was considered as statistically significant. Pearson’s chi-square statistic was used to test for differences in data expressed as frequen-cies, and independent two-tailed t-tests were used to determine whether there was a difference between groups.

Table 1. Demographics and selected postoperative parameters for patients in groups I and II

Features Group 1 Group 2 P-value

Age (yr) 42.5±1.2 43.1±2.9 NS

Sex (M/F) 17/1 8/0 NS

White blood cell (cells/cu mm) 10000±5600 18000±12000 <0.001

Platelet (platelets/ mL) 350000±180000 80000±120000 <0.001

Prothrombin time (sec) 13.8±0.37 14.6±0.56 NS

Urea (mg/dL) 80±30 130±50 <0.01

Creatinine (mg/dl) 1.68±0.73 2.1±1.23 <0.05

AST 2000±350 2500±100 NS

ALT 1500±200 1800±100 NS

Figure 1. Showing early leucocytosis secondary to infection as an important predictor of early morbidity and mortality in Group 2

WBC COUNT - Group 2WBC COUNT - Group 1

Postoperative deaths in DDLT 85


groups. Group 1 patients had a mean prothrombin time of 13.8±0.37 Sec while in Group 2 patients it was 14.6±0.56 Sec. International normalized ratio (INR) was also significantly higher in Group 2 patients compared to Group 1 (Figure 4). Transaminases showed a significant rise between the 2nd and 3rd postoperative day, after which they stabilized and showed a downward trend by the 7th to 9th postoperative day in both groups. Group 2 patients showed high levels of ammonia compared to Group 1. However, this differ-ence was not statistically significant. The causes of death were intraoperative events like cardiac arrhythmias, and in ischaemic cardiac events (3), pulmonary thromboem-bolism (1), sepsis and multiorgan failure (4). Two patients required renal replacement therapy for resistance renal failure in Group 2.

predictor for early morbidity and mortality 10000±5600cells/cu mm and 18000±12000 cells/cu mm in Groups 1 and 2, respectively. This difference was statistically significant (P<0.01) (Figure 1). Serum urea showed a significant eleva-tion in Group 2 as opposed to Group 1 (P<0.01). Serum creatinine was increased in both groups, but was much higher in Group 2 compared to Group 1: serum creatinine was 2.1±1.23 in Group 2 and 1.68±0.73 in Group 1. This difference was statistically significant (P<0.05) (Figure 2). A significant fall in platelet count predicted mortality. The se-rum platelet count in Group 1 was 350000±180000 platelets/ ml, whereas in Group 2 it had dropped to 80000±120000 platelets/ ml. This reduction was statistically significant (P<0.001) (Figure 3). Prothrombin time correlated well with the outcome, although the trend was the same in both

Figure 2. Serum creatinine was increased in both groups, but was much higher in Group 2 compared to Group 1

Figure 3. Showing that a significant fall in platelet count predicted mortality in Group 2

Platelets - Group 2Platelets - Group 1

Creatinine - Group 2Creatinine - Group 1

86 Arunkumar Krishnan et al


Discussion

Predicting the outcome soon after liver transplantation remains an elusive goal, although the need to anticipate the result of a therapeutic intervention is particularly compel-ling in life-saving organ transplantation. We would like to determine early on whether an organ is destined to fail, since prompt intervention might ameliorate the increased morbidity and mortality that accompany retransplantation..

Our study recommends that routine blood tests may help to anticipate an early loss of liver grafts after transplantation and could indicate further investigation or intervention. Constant assessment of the liver graft function is possibly the most important element in early postoperative manage-ment after transplantation. [7]

Our results showed that all patients had abnormal levels of white blood cells, creatinine, INR, and platelets; however, only the high baseline levels of creatinine, low platelet and white blood cell count were identified as prognostic factors. As baseline transaminases correlate with graft outcome, it could be suggested that patients with elevated AST/ALT were those with acute liver failure who received poorer grafts [8]. However, such abnormalities in the transaminases of our patients showed a significant rise between the 2nd and 3rd postoperative day, after which they stabilized and showed a downward trend by the 7th-9th postoperative day in both groups.

Higher prognostic levels of creatinine may confirm the rapid development of acute renal failure and multiorgan failure cases of graft failure. It is quite common to find high values of laboratory parameters in the postoperative period. [9] These laboratory parameters can persist and start to de-crease after 48 h or more and cannot be of prognostic value. In our study, all the patients in Group 2 showed significantly high creatinine levels at every post-transplantation phase.

Serum creatinine has been previously identified by our group as the best single preoperative indicator of short-term prognosis after liver transplantation. [10]

We acknowledge that a limitation in this study is its small sample size. The study demonstrated that high white blood cell count, platelet and serum creatinine levels were independent risk factors for mortality. In summary, post-operative, persistent leukocytosis, and sepsis and cardiac events in the immediate postoperative period predict an outcome post DDLT.

Conflict of Interest

The authors declare that there is no conflict of interest.

References

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2. Cacciarelli TV, Esquivel CO, Moore DH, Cox KL, Berquist WE, Concepcion W, et al. Factors affecting survival after orthotopic liver transplantation in infants. Transplantation 1997; 64:242-8

3. Ganschow R, Nolkemper D, Helmke K, Harps E, Commentz JC, Broering DC, et al. Intensive care management after pediatric liver transplantation: a single-center experience. Pediatr Transplant 2000; 4:273–9

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5. Jain A, Mazariegos G, Kashyap R, Kosmach-Park B, Starzl TE, Fung J, et al. Pediatric liver transplantation. A single

Figure 4. Showing INR to be significantly higher in Group 2 patients compared to group 1

INR - Group 2INR - Group 1

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center experience spanning 20 years. Transplantation 2002; 73:941–7

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10. Cuervas-Mons V, Millan I, Gavaler JS, Starzl TE, Van Thiel DH. Prognostic value of preoperatively obtained clinical and laboratory data in predicting survival following orthotopic liver transplantation. Hepatology 1986; 6:922

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Early postoperative deaths of recipients after deceased donor liver transplantation