David S Goldberg1, Karen Krok2, Sachin Batra3, James F Trotter4, Steven M Kawut5, Michael B Fallon3. 1. Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Clinical Center for Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: david.goldberg@uphs.upenn.edu. 2. Division of Gastroenterology, Department of Medicine, Hershey Medical Center, Hershey, Pennsylvania. 3. Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas. 4. Department of Hepatology, Baylor University Simmons Transplant Institute, Dallas, Texas. 5. Clinical Center for Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
Abstract
BACKGROUND & AIMS: Patients with hepatopulmonary syndrome (HPS) are prioritized for liver transplantation (given exception points) due to their high pre- and post-transplantation mortality. However, few studies have evaluated the outcomes of these patients. METHODS: We performed a retrospective cohort study using data submitted to the United Network for Organ Sharing in a study of the effects of room-air oxygenation on pre- and post-transplantation outcomes of patients with HPS. We identified thresholds associated with post-transplantation survival using cubic spline analysis and compared overall survival times of patients with and without HPS. RESULTS: From 2002 through 2012, nine hundred and seventy-three patients on the liver transplant waitlist received HPS exception points. There was no association between oxygenation and waitlist mortality among patients with HPS exception points. Transplant recipients with more severe hypoxemia had increased risk of death after liver transplantation. Rates of 3-year unadjusted post-transplantation survival were 84% for patients with PaO2 of 44.1-54.0 mm Hg vs 68% for those with PaO2 ≤ 44.0 mm Hg. In multivariable Cox models, transplant recipients with an initial room-air PaO2 ≤ 44.0 mm Hg had significant increases in post-transplantation mortality (hazard ratio = 1.58; 95% confidence interval [CI]: 1.15-2.18) compared with those with a PaO2 of 44.1-54.0 mm Hg. Overall mortality was significantly lower among waitlist candidates with HPS exception points than those without (hazard ratio = 0.82; 95% CI: 0.70-0.96), possibly because patients with HPS have a reduced risk of pre-transplantation mortality and similar rate of post-transplantation survival. CONCLUSIONS: Although there was no association between pre-transplantation oxygenation and waitlist survival in patients with HPS Model for End-Stage Liver Disease exception points, a pre-transplantation room-air PaO2 ≤ 44.0 mm Hg was associated with increased post-transplantation mortality. HPS Model for End-Stage Liver Disease exception patients had lower overall mortality compared with others awaiting liver transplantation, suggesting that the appropriateness of the HPS exception policy should be reassessed.
BACKGROUND & AIMS:Patients with hepatopulmonary syndrome (HPS) are prioritized for liver transplantation (given exception points) due to their high pre- and post-transplantation mortality. However, few studies have evaluated the outcomes of these patients. METHODS: We performed a retrospective cohort study using data submitted to the United Network for Organ Sharing in a study of the effects of room-air oxygenation on pre- and post-transplantation outcomes of patients with HPS. We identified thresholds associated with post-transplantation survival using cubic spline analysis and compared overall survival times of patients with and without HPS. RESULTS: From 2002 through 2012, nine hundred and seventy-three patients on the liver transplant waitlist received HPS exception points. There was no association between oxygenation and waitlist mortality among patients with HPS exception points. Transplant recipients with more severe hypoxemia had increased risk of death after liver transplantation. Rates of 3-year unadjusted post-transplantation survival were 84% for patients with PaO2 of 44.1-54.0 mm Hg vs 68% for those with PaO2 ≤ 44.0 mm Hg. In multivariable Cox models, transplant recipients with an initial room-air PaO2 ≤ 44.0 mm Hg had significant increases in post-transplantation mortality (hazard ratio = 1.58; 95% confidence interval [CI]: 1.15-2.18) compared with those with a PaO2 of 44.1-54.0 mm Hg. Overall mortality was significantly lower among waitlist candidates with HPS exception points than those without (hazard ratio = 0.82; 95% CI: 0.70-0.96), possibly because patients with HPS have a reduced risk of pre-transplantation mortality and similar rate of post-transplantation survival. CONCLUSIONS: Although there was no association between pre-transplantation oxygenation and waitlist survival in patients with HPS Model for End-Stage Liver Disease exception points, a pre-transplantation room-air PaO2 ≤ 44.0 mm Hg was associated with increased post-transplantation mortality. HPS Model for End-Stage Liver Disease exception patients had lower overall mortality compared with others awaiting liver transplantation, suggesting that the appropriateness of the HPS exception policy should be reassessed.
Authors: Vivek N Iyer; Karen L Swanson; Rodrigo Cartin-Ceba; Ross A Dierkhising; Charles B Rosen; Julie K Heimbach; Russell H Wiesner; Michael J Krowka Journal: Hepatology Date: 2013-02-15 Impact factor: 17.425
Authors: P S Kamath; R H Wiesner; M Malinchoc; W Kremers; T M Therneau; C L Kosberg; G D'Amico; E R Dickson; W R Kim Journal: Hepatology Date: 2001-02 Impact factor: 17.425
Authors: Peter Schenk; Maximilian Schöniger-Hekele; Valentin Fuhrmann; Christian Madl; Gerd Silberhumer; Christian Müller Journal: Gastroenterology Date: 2003-10 Impact factor: 22.682
Authors: Russell Wiesner; Erick Edwards; Richard Freeman; Ann Harper; Ray Kim; Patrick Kamath; Walter Kremers; John Lake; Todd Howard; Robert M Merion; Robert A Wolfe; Ruud Krom Journal: Gastroenterology Date: 2003-01 Impact factor: 22.682
Authors: Steven M Kawut; Susan S Ellenberg; Michael J Krowka; David Goldberg; Hugo Vargas; David Koch; Tiffany Sharkoski; Nadine Al-Naamani; Alyson Fox; Robert Brown; Joshua Levitsky; Jae K Oh; Grace Lin; Nianfu Song; Carl Mottram; Margaret F Doyle; David E Kaplan; Samir Gupta; Michael B Fallon Journal: Liver Transpl Date: 2019-05-30 Impact factor: 5.799
Authors: Kimberly A Forde; Michael B Fallon; Michael J Krowka; Michael Sprys; David S Goldberg; Karen L Krok; Mamta Patel; Grace Lin; Jae K Oh; Carl D Mottram; Paul D Scanlon; Steven M Kawut Journal: Hepatology Date: 2018-12-18 Impact factor: 17.425