Australian National Liver Transplantation Unit€¦ · 1675 liver transplants on 1544 patients have been performed at ANLTU. In 2016, 98 new, 14 secondary and 1 tertiary orthotopic

Australian National Liver

Transplantation Unit

© copyright ANLTU Data to 31 December 2016

0

10

20

30

40

50

60

70

80

90

100

110

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Child (n = 333)

Adult (n = 1342)

Data to 31 December 2016

Data to 31/12/2016 © copyright ANLTU

Contents Preface ......................................................................................................................................... i

Summary ...................................................................................................................................... i

ASSESSMENT INFORMATION ............................................................................................................................. 1

Allocation of Assessed Adults/Children ...................................................................................... 2

Patients Considered Unsuitable for Transplantation (Adults) .................................................... 2

Comparison Over Time Of Patients Assessed ............................................................................. 3

Waiting List Activity ..................................................................................................................... 4

Urgent Listings ............................................................................................................................ 5

Age and Waiting Time of Transplant Recipients (Primary Grafts) .............................................. 6

DONOR INFORMATION ...................................................................................................................................... 8

Deceased Donor Offers ............................................................................................................... 9

DBD Donor Offers...................................................................................................................... 13

DCD Donor Offers ...................................................................................................................... 13

Allocation of Accepted and Utilised Deceased Donor Offer Livers 2016 ................................. 14

Living Donor Procedures – Paediatric & Adult .......................................................................... 14

Deceased Donor Age by Era (Median) ...................................................................................... 15

Donors over 50 years ................................................................................................................ 15

Deceased Donor Cause of Death .............................................................................................. 16

RECIPIENT DEMOGRAPHICS ............................................................................................................................ 18

Patient Age at Transplant.......................................................................................................... 19

Primary Hepatic Disease ........................................................................................................... 19

Chronic Viral and Auto-Immune Hepatitis ................................................................................ 21

Fulminant Hepatic Failure as Primary Indication Treated by Liver Transplantation ................ 22

HCC and Associated Disease ..................................................................................................... 23

NASH/NAFLD by Era .................................................................................................................. 24

Indication For Secondary Transplantation ................................................................................ 25

PERIOPERATIVE DATA ...................................................................................................................................... 26

Mean/Median Hospital Stay ..................................................................................................... 27

Red Cell Usage ........................................................................................................................... 27

Graft Ischaemic Time, Operation Duration and Red Cell Utilisation ........................................ 27

OUTCOME DATA .............................................................................................................................................. 28

Patient Survival ......................................................................................................................... 29

Primary Disease and Outcome .................................................................................................. 33

Status at Transplant vs Patient Outcome ................................................................................. 34

Chronic HBV Outcomes ............................................................................................................. 36

Chronic HCV Outcomes ............................................................................................................. 37

Donor Age vs Primary Graft Outcome ...................................................................................... 40

Steatosis vs Graft Outcome (Adults) ......................................................................................... 41

Graft Survival ............................................................................................................................. 42

Split vs Reduced vs Whole Grafts ............................................................................................. 45

Auxiliary Transplant Survival ..................................................................................................... 47

Cause of Death .......................................................................................................................... 48

Cause of Graft Failure ............................................................................................................... 53

CANCER AND TRANSPLANTATION ................................................................................................................... 57

Malignancy at Transplantation ................................................................................................. 58

De Novo Non Skin Cancer Post Transplant ............................................................................... 61

Pre Transplant Liver Disease and De Novo Non Skin Cancer .................................................... 62

Cumulative Risk of Diagnosis of Cancer .................................................................................... 64

Data to 31 December 2016 © copyright ANLTU i

Preface

The 30 year anniversary of the first liver transplant occurred during 2016. Since January 1986

1675 liver transplants on 1544 patients have been performed at ANLTU.

In 2016, 98 new, 14 secondary and 1 tertiary orthotopic liver transplant procedures were

performed within the ANLTU (27 – The Children’s Hospital at Westmead; 86 – Royal Prince Alfred

Hospital). This included the ongoing usage of split liver allografts and the use of extended criteria

donor liver allografts, which maximise the limited donor resources available.

The staff within the ANLTU would like to thank the members of the departments within Royal

Prince Alfred Hospital and Sydney Local Health Network who have helped contribute to the

success of the program in the past year. This includes Haematology, Biochemistry, other

Laboratory services, Blood Bank, Department of Pathology, Department of Renal Medicine,

Intensive Care Unit, Operating Room, Department of Psychiatry, Department of Cardiology,

Department of Respiratory Medicine, Dietetic Department, Department of Social work,

Department of Anaesthesia, the Casemix unit and all the other people who have not been

specifically mentioned.

We would also like to thank the other departments within the Children’s Hospital at Westmead,

who have helped contribute to the success of the paediatric programme. These include the

membership of Department of Anaesthesia, the Intensive Care Unit, Laboratory services staff,

Department of Social Work, Department of Nutrition and other medical departments.

The staff of the Australian Red Cross Blood Service are also acknowledged for their assistance

during the year.

Finally, without the generosity of the deceased organ donors and their families, liver

transplantation would not be able to proceed at this level. Hence we give our thanks to them as

well as to the team at Donate Life NSW, Kogarah.

Professor Geoff McCaughan

Dr Deborah Verran

Dr Michael Crawford

Gavin Lackey

Data to 31 December 2016 © copyright ANLTU ii

Summary

Summary

There are several key issues to report.

1. In 2016 there were:

113 orthotopic liver transplant procedures

107 new listings on the Waiting List

40 patients on the Waiting List at the end of the year

2 Donations after Circulatory Death

8 Paediatric Donors

2. In 2016, 98 new, 14 secondary and 1 tertiary orthotopic liver transplant procedures

were performed, 27 of which were Paediatric and 86 were Adult.

3. Between January 1986 to December 2016, 1675 liver transplants were performed on

1544 patients, of which 1257 and 287 recipients were adults and children, respectively.

4. The number of transplants per year continues to be related to the deceased donor rate.

5. In 2016, 16 patients (9%) on the waiting list were subsequently withdrawn due to

advanced and/or extra-hepatic disease. Five patients improved whilst on the waiting

list.

6. The movement of patients on and off the waiting list continues to be dynamic.

7. The average waiting time for adults in all blood groups remains variable depending on

blood group.

8. The median deceased donor age has increased from 30 years (1986 – 1996) to 45 years

(2007 – 2016). In 2016 there were seven deceased donors over the age of 70 years.

9. The median age for adult recipients has increased from 46.7 years (1986 – 1996) to now

stand at 52.1 years. The median age for child recipients has decreased from 3.7 years

(1986 – 1996) and now stands at 2.2 years.

10. HCV infection has been an increasing primary and secondary indication for liver

transplantation in adults. In the period 1986 – 1996 12% of adults had this diagnosis

compared to 39% in 2007 – 2016.

11. Hepatocellular carcinoma has also become an increasingly common primary and

secondary indication for liver transplantation, with 33% of the adult recipients having a

diagnosis of HCC in the five year period 2012 – 2016.

12. The overall patient survival rate over the past 2 years was 93% at one year.

Data to 31 December 2016 © copyright ANLTU 1

ASSESSMENT INFORMATION


Allocation of Assessed Adults/Children


Allocation of Patients Accepted for Assessment

Accepted68%

Deferred11%

Unsuitable19% Died Pre-

List2%

Adults (n = 2452)

Accepted89%

Deferred4%

Unsuitable7%

Children (n = 374)

Patients Considered Unsuitable for Transplantation (Adults)


Patients Considered Unsuitable for Transplantation2452 Adults have been assessed since 1985

Reason Adults

Too Advanced + extra-hepatic disease 171 37

Tumour Progression + Tumour (extra-hepatic spread) 76 16

Good prognosis 66 14

Psychological 15 13

Alcohol 57 12

Patient’s wish 24 5

Alternative therapy 7 1

Age 5 1

Condition improved 2 0.4

Logistics 1 0.2

Total 470 100%


Comparison Over Time Of Patients Assessed

Comparison Over Time of Patients Assessed


1985 - 1996

Accepted48%

Deferred18%

Unsuitable34% Died

Pre-List

0.1%

Adults (n = 739)

Accepted73%

Deferred11% Unsuitable

16%

Children (n = 126)


1997 - 2006

Accepted64%

Deferred15%

Unsuitable19%

Died Pre-List2%

Adults (n = 914)

Accepted94%

Deferred2%

Unsuitable4%

Children (n = 125)


2007 - 2016

Accepted90%

Deferred1%

Unsuitable5%

Died Pre-List4%

Adults (n = 799)

Accepted99%

Unsuitable1%

Children (n = 123)

Adult patient acceptance rate has increased from 48% in the period of 1985 – 1996 to 90% in

2007 – 2016.

Child patient acceptance rate has increased from 73% in the period of 1985 – 1996 to 99% in

2007 – 2016.


Waiting List Activity


Waiting List Activity

Year

Listed at

Start of

Year

New

ListingsTotal

Pts

Tx

Died

Pre Tx

Withdrawn Total

Withdrawn/

Mortality

ImprovedListed at

End of YearTumour

ProgressedOther

2007n 46 95 141 54 19 2 2 23 2 63

% 38 13 1 1 16 1

2008n 63 76 139 59 25 2 5 32 5 43

% 42 18 1 3.5 23 3.5

2009n 43 97 140 59 11 3 5 19 8 54

% 42 8 2 3.5 13.6 5.7

2010n 54 98 152 77 6 4 2 12 2 61

% 51 4 3 1 8 1

2011n 61 82 143 71 9 5 2 16 4 52

% 50 6 3 1 11 3

2012n 52 104 156 75 15 2 9 26 2 53

% 48 10 1.3 6 17 1.3

2013n 53 113 166 80 15 5 11 31 3 52

% 48 9 3 7 19 2

2014n 52 112 164 76 5 1 14 20 4 64

% 46 3 0.6 9 12 2

2015n 64 122 186 98 3 3 13 19 1 68

% 53 2 2 7 10 .5

2016n 68 107 175 107 5 8 3 16 9 40

% 61 2 3 1 9 5


63

43

54

61

52

53

52

64

68

40

0 10 20 30 40 50 60 70 80

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Patients on Waiting List at the end of Calendar Yea r



16

23

14

8

11

1719

1210 9

1

3.5

6

1

3

1

2

2

0.5

5

0

5

10

15

20

25

30

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Improved

Withdrawn/Mortality

% Patients Withdrawn from Waiting List

Urgent Listings


Urgent Listings 2016

Number of Patients Listed as

Urgent

Share

35Cat 1 Cat 2 Total

Transplanted 2 5 9 16

Died Pre-Transplant 1 1

Permanently Delisted 1 1

Died Post-Transplant on waiting list 2 2

Total 3 7 10 20


Age and Waiting Time of Transplant Recipients (Primary Grafts)


Age of Transplant Recipients (Primary Grafts)

n 69 91 126

Median 3.7 2.4 1.4

Mean 5.4 4.2 3.6

Children

n 286

Median 2.2 years

Mean 4.2 years

Range 0.1 – 15.6 years

n 280 402 574

Median 46.7 50.7 54.6

Mean 44.3 49.5 52.8

Adults

n 1256

Median 52.1 years

Mean 49.8 years

Range 16.1 – 69.5 years

2030

4050

6070

Age

at T

rans

plan

t - Y

ears

1986 - 1996 1997 - 2006 2007 - 2016

05

1015

Age

at T

rans

plan

t - Y

ears

1986 - 1996 1997 - 2006 2007 - 2016


Waiting Time of Transplant Recipients (Primary Graf ts)Children

Median 2.26 months

Mean 5.02 months

Max 76.49 months

Adults

Median 2.43 months

Mean 5.71 months

Max 95.48 months

Median 1.80 6.33 5.17

Mean 3.02 2.39 2.33

Max 14.49 48.10 76.49

Median 0.80 2.82 4.49

Mean 1.32 5.20 8.20

Max 7.80 69.25 95.48

05

1015

20M

onth

s W

aitin

g

1986 - 1996 1997 - 2006 2007 - 2016

05

1015

2025

Mon

ths

Wai

ting

1986 - 1996 1997 - 2006 2007 - 2016



5.5

8.9 9

3.6

1.6

3.3

9.7

12.7

5.9

11.7

6.6

8

0

2

4

6

8

10

12

14

2007 - 2009 2010 - 2012 2013 - 2016

A

AB

B

O

Adult Mean Months WaitingPrimary Liver Transplantation vs ABO (2007 – 2016)


2007 – 2009 2010 – 2012 2012 – 2016 Overall

A 5.5 9.0 8.9 8.3

AB 3.6 1.6 3.3 3.0

B 9.7 12.7 5.9 8.6

O 11.7 6.6 8.4 8.7

Mean 8.7 8.4 7.9 8.2

Adult Mean Months WaitingPrimary Liver Transplantation vs ABO (2007 – 2016)


DONOR INFORMATION


Deceased Donor Offers


46

52 51

66

61

69

74

69

79

101

42 3 4 4

2 2 2

108

1 2 36 5

2 35

8

2

0

20

40

60

80

100

120

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Adult DBD Paediatric DBD Adult DCD

Deceased Adult and Paediatric Donor Organs Used By Year

Since 2000, 93.6% of liver donors were adults (>=15yrs) and 6.4% were paediatric donors.


Deceased Donor Offers to NSW 2007 - 2016Donor Type State 2007 - 2009 2010 - 2012 2013 – 2015 2016 Total

DBD

ACT 12 20 24 14 70

NSW 147 194 240 101 682

NT 3 2 3 1 9

NZ 9 10 12 7 38

QLD 23 18 24 19 84

SA 15 9 21 6 53

TAS 4 1 2 1 8

VIC 19 32 20 10 81

WA 8 15 18 7 48

Total BDD Offers 240 303 364 166 1073

BDD Used 137 186 217 103 643

DCD

ACT 6 6 4 1 17

NSW 41 66 49 16 172

NT 1 1 2

NZ 1 1

QLD 2 1 3

SA 1 1

TAS 1 1

VIC 1 7 6 4 18

WA 1 1

Total DCD Offers 48 81 63 24 216

DCD Used 7 15 13 2 40

Total Offers 288 384 427 190 1289

Total Used 144 201 233 105 683



DBD Donor Offers Declined 201664/167 (38.3%)

Declined at

Offer

Declined at

Hepatectomy

Abnormal LFTs 7

Cirrhosis 3

Donor age 1

Donor history * 15

Donor malignancy - extrahepatic 1

Donor obesity 1

High risk donor for tumour or infection 1

Impaired perfusion/ischaemia 2

Interstate donor not suitable for directed recipient (Urgent Case) 5 1

Liver fibrosis 1

No suitable ABO compatible recipient/No suitable recipient 7

Offer waived for urgent Tx elsewhere 6

Positive virology 1

Steatosis 4

Unstable 2

Vascular issues 1

Other ** 1 4

TOTAL 46 18


DBD Donor Offers Declined 201664/167 (38.3%)

*Donor

history

1 Age, Hx HT, diabetes, initially accepted however plaque in HA found on CT.

2Long downtime, heavy drinker, long ischaemic time from WA, raised LFT's. High risk (sexual

activity and prison - NAT neg).

3 Mammalian Protein Allergy with potential anaphylaxis reactions if eating meat.

4 Multiorgan failure.

5 Recent unexplained weight loss, jaundice, IVDU, hep c, downtime.

6 Extended criteria donor unstable, high lactate downtime high risk primary non function.

7 Severe lv dysfunction ef 15%, acidotic , LFTs, ext downtime.

8 High bili (77), low plt, high etoh, likely liver disease, serology hcv pos.

9 Donor history of itp.

10Age, extensive medical hx (cardiovascular), rabdo, downtime, interstate (cold time). No patients

sick enough to risk.

11 History of hydatid disease and pseudooxantheroma elasticum.

12 Technically not possible to retrieve liver due to aortic dissection, massive blood loss.

13 Unusable graft, acidotic, coagulopathic, abnormal lfts, unstable.

14 HCV pos (on nat), hx alcoholic, long cit, ht, chol, smoker.

15Cocaine and probable heroin od, rehab for etoh, heavy drinker, 57 mins downtime, hcv pos,

raised lft's. No patients sick enough to justify risk.



DCD Donor Offers Declined 201624/26 (92.3%)

Declined at

Offer

Declined at

Hepatectomy

Abnormal LFTs 1

Consent withdrawn/relatives refused consent 1

DCD did not proceed to hepatectomy 7

Donor history * 4

Donor obesity 1

Interstate donor not suitable for directed recipient (Urgent case) 1

No suitable recipient 1

Outside DCD acceptance criteria 5

Steatosis 1 2

TOTAL 15 9

* Donor history 1 DCD and in Tasmania, Vic already turned down.

2Hx of complicated cholecystectomy, biliary leak requiring stents, ERCP's strictures, ongoing

deranged LFTs.

3 HCV +ve Donor/Opiates unsure window period/Polypharmacy.

4 60mins + downtime, unknown cause of death, ischaemic hepatitis, IVDU


Enquiries Declined 2016

Declined at

Enquiry

Abnormal LFTs 5

Cirrhosis 2

Consent withdraw/relatives refused consent 4

Donor age 6

Donor history * 19

Donor obesity 1

High risk donor for tumour or infection 5

Interstate donor not suitable for directed recipient (Urgent Case) 1

Known liver disease 1

No suitable ABO compatible recipient 3

No suitable recipient 6

Not suitable for designated recipient 2

Offer waived 1

Outside DCD acceptance criteria 3

Unstable 1

Vascular issues 1

Other ** 10

TOTAL 71




* Donor

history

1Congenital syndromes, ? Biliary tree malformation with Turners syndrome. DCD. No pts sick enough to

risk.

2 ECMO, high inotropes, downtime 55 mins.

3 Methamphetamine, Sexual contacts, IVDU, 72 mins downtime, LFTs.

4 OOHCA extended downtime abnormal LFTs.

515 days ICU, extensive hx including congenital hrt disease, Eisenmenger syndrome, polycythemia.

Ongoing sepsis ? Source.

6Verbal DCD interstate offer for our Share 35 urgent, simultaneous with BDD offer more suitable. HCV,

logistics, not consented.

7HCV and HBcAg +, IVDU. No patients currently suitable to accept risk. Offered interstate. Nil organs

accepted.

8DCD>50 known vascular disease not seen for many days, rhabdomyolysis, likely hepatic micro emboli, not

medically suitable.

9 Methamphetamine, known IVDU, ETOH.

10 DCD outside criteria (age).

11 HCV and HIV pos never treated. Current IVDU.

12Hx fatty liver, BMI 38, alcohol abuse, raised LFTs. Requested rpt U/S which showed fatty liver. Also

concerns re system infection (pos blood cultures). All organs declined.

13 Age, diabetic, bladder ca, MALT lymphoma (radiotherapy) previous heavy drinker.

14Extensive medical hx MGUS, AAA, abdo surgery, cardiac hx. Tried to source reports etc but declined due

to difficulty with donor surgery, risks, vasculopath. Nil organs retrieved.

15 Bowel resection, endoanal tumour, high risk of donor tumour.

16Age, Hx CVA, COPD, CKD, heavy smoker. Decline due to age, hx and risk of calcified vessels, no pts sick

enough to risk.

17Ischaemic hepatitis in an elderly patient/AST > 750 ALT > 750 not medically suitable. Not yet BD at

enquiry.

18 40 yr hx type 1 diabetes, HT, high chol and 87 years. Also risk of fatty liver.

19 DCD, kidneys rejected, ETOH, heavy smoker, recent large weight loss.



** Other 1 Did not proceed to offer. HCV pos donor. We were interested however NZ accepted.

2 No diagnosis, too many unknowns in a 10 month microcephalic paediatric donor.

3 Anencephalic 36 week old foetus to be DCD. Donor too small and situation too complicated.

4No patients sick enough to justify high risk. HCV, LT IVDU, ETOH binge, prison, tattoo, recent

sexual assault, high inotropes.

5Did not proceed to formal offer. Were awaiting BD confirmation but pt died suddenly. Significant

cardiac and renal hx. Would have been liver only donor.

6Did not progress to formal offer/BD. Hx dementia, malnutrition, pacemaker, COPD, CAGS,

ureteric stent.

7Did not proceed to formal offer. We did not exclude this offer and would consider if progressed

to formal EDR. Did not progress to BD.

8Did not proceed as a donor. We were interested if they thought BD but deemed would probably

not progress and treatment withdrawn.

9 DCD with > 1hr downtime. Became kidney and heart valve donor.

10Enquiry for HCV treated potential donor, did not progress to BD. Proceeded to DCD for kidney

and lung.


DBD Donor Offers


47 48

6062

6468

66

83

103

119

12 11

20

25

1618 18

30

2325 26

23

28

20

40

46

0

20

40

60

80

100

2008 2009 2010 2011 2012 2013 2014 2015 2016

Used Declined at Hepatectomy Declined at Offer

DBD Donor Offers to NSW

DCD Donor Offers


2

4

8

5

2

3

5

8

2

6

8

10

5

9

7

8

13

9

8

11

18

9

15

7

6

5

15

0

2

4

6

8

10

12

14

16

18

20

2008 2009 2010 2011 2012 2013 2014 2015 2016

Used Declined at Hepatectomy Declined at Offer

DCD Donor Offers to NSW


Allocation of Accepted and Utilised Deceased Donor Offer Livers 2016


Allocation of Accepted and Utilised Deceased Donor Livers

1st Recipient Allocation Total

DBD

Highest prioritised patient suitable for this type of graft 86

Size of graft not suitable for higher priority patient(s) 11

Higher priority patient(s) medically unfit 1

Higher priority patient(s) has HCV and older donor

Logistical reasons not suitable for higher priority patients 1

Positive donor virology 1

Other * 3

DCD Highest prioritised patient suitable for this type of graft 2

Total 105

2nd Recipient Allocation

DBD

Highest prioritised patient suitable for this type of graft 6

Higher priority patient(s) medically unfit 1

Size of graft not suitable for higher priority patient(s) 1

Total 8

* Other 1 Good size match for paed recipient's 3rd transplant

2 Initially accepted by QLD on rotation was waived to NSW for Cat 2a

3 Liver/lung - suitable match for lungs

Living Donor Procedures – Paediatric & Adult


Living Donor Procedures – Paediatric and Adult

* The Living Unrelated Donor Procedures in 2003 and 2013 were adult domino transplants.

** The Living Unrelated Donor Procedure in 2011 was adult to adult.

Year 1990 2002 2003 2004 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Total

TypeLRD LRD LUD

*

LRD LRD LRD LRD LRD LRD LUD

**

LRD LUD

*

LRD LRD

Total 1 1 1 1 2 3 3 2 3 1 2 1 0 1 2 24


Deceased Donor Age by Era (Median)


020

4060

80D

onor

Age

- Y

ears

1986 - 1996 1997 - 2006 2007 - 2016

Deceased Donor Age by Era

n 382 525 744

Median 30 42 45

Mean 31.7 39.3 43.1

n = 1651

Median 40 years

Mean 39.2 years

Range 0.01 – 87 years

The donor age ranged from 0 to 87 years, with a mean value of 40 years.

Donors over 50 years


1 2 1 1

58

10

3 4 57

9 96

8

47

18

118 8

14

9 1012

17

10

1517

28

1

4

3

1

3 1

3

86

32

4

4

6

8

5 5

7

9 7

13

13

11

9

14

11

2

22

3

5

2

5

1

2

6

4

3

7

8

7

6

1

1

21

3

1

0

5

10

15

20

25

30

35

40

45

50

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

> 80 (n = 9)

71 - 80 (n = 65)

61 - 70 (n = 161)

51 - 60 (n = 267)

Deceased Donors Over 50 Years(n = 502)


Deceased Donor Cause of Death


Hypoxia/Anoxia16%

Cerebrovascular Accident

48%

Tumour1%

Road Trauma21%

Other Trauma11%

Other2% Suicide

1%

Hypoxia/AnoxiaCerebrovascular AccidentTumourRoad TraumaOther TraumaOtherSuicide

Deceased Donor Cause of Death(n = 1651)

799 (48%) donors died due to cerebral haemorrhage, 525 (33%) died due to trauma.


35

50

174

167

294

338

7

3

7

126

122

103

43

45

86

3

3

6

1

8

30

0 50 100 150 200 250 300 350 400

1986 - 1996

1997 - 2006

2007 - 2016

OtherSuicideOther TraumaRoad TraumaTumourCerebrovascular AccidentHypoxia/Anoxia

Deceased Donor Cause of Death by Era

Deaths due to trauma were 44% (1986 – 1996), 32% (1997 – 2006) and 25% (2007 – 2016). In

these same time periods, deaths due to cerebral causes were 44%, 56% and 45%.



7

2321

33

46

40

48

40

53

59

20

17

1315

1112 12

21

1817

23

6

10

56

3 32

3

6

2

7

21 1 1

0

5

10

15

20

25

30

35

40

45

50

55

60

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

S0 (n = 370)

S1 (n = 156)

S2 (n = 43)

S3 (n = 20)

Adult Graft Steatosis 2007 - 2016

Steatosis Scoring:

S0 less than 5% steatosis in biopsy (either macro or micro)

S1 Ma/Mi 5 – 29% Macrovesicular steatosis on biopsy combined with varying degrees of Micro

S2 Ma/Mi 30 < 60% Macrovesicular steatosis on biopsy combined with varying degrees of Micro

S3 Ma/Mi 60 +% Macrovesicular steatosis on biopsy combined with varying degrees of Micro

Since 2007 there are 19 cases (3.1%) where post reperfusion biopsy was not performed.


RECIPIENT DEMOGRAPHICS


Patient Age at Transplant


86 75

119

220

304

526

164

48

-50

50

150

250

350

450

550

< 1 1 - 3 4 - 15 16 - 40 41 - 50 51 - 60 61 - 65 > 65

Breakdown of Patient Age at Primary Transplant(n = 1542)

The modal group was in the age range 51 – 60 years (34.1%).

Primary Hepatic Disease


Biliary Atresia11%

Malignancy9%

HCV19%

Metabolic9%

Fulminant10%

ALD10%

CC2%

PSC8%

PBC5%

Other4%

AIH4%

HBV5%

B,C1%

NASH/NAFLD3%

Primary Disease – All Patients(n = 1542)

The most common primary indications for transplantation are Chronic Hepatitis C (292, 19%),

Biliary Atresia (165, 11%), Alcoholic Disease (158, 10%) and Fulminant Liver Failure (150, 10%).



Biliary Atresia1%

Malignancy11%

HCV23%

Metabolic6%

Fulminant9%

ALD13%

CC2%

PSC10%

PBC6%

Other4%

AIH4%

HBV7%

B,C1% NASH/NAFLD

3%

Primary Disease – Adults(n = 1256)

Hepatitis C was the most common indication of transplantation in adults (292, 23%), followed by

Alcoholic Liver Disease (ALD 158, 13%), Malignancy (137, 11%), Primary Sclerosing Cholangitis (PSC

126, 10%), Fulminant Hepatic Failure (119, 19%), and Hepatitis B (83, 7%).


Biliary Atresia54%

Malignancy3%

Metabolic21%

Fulminant11%

CC1% Other

8%AIH2%

Primary Disease – Children(n = 286)

The most common indication for transplantation in children was Biliary Atresia (154, 54%),

followed by Metabolic disease (62, 21%) and Fulminant Hepatic Failure (31, 11%).


Chronic Viral and Auto-Immune Hepatitis


Chronic Viral and Auto-Immune HepatitisPrimary and Secondary

n = 581 (46.3% of all Adults)

AIH9% B, C

2%

HCV64%

HBV22%

HDV3%

Viral91%

Auto-Immune Hepatitis (AIH) comprised 9% of cases, the remainder (91%) being viral in origin

(CVH). Of the cases of viral hepatitis, the most common is Hepatitis C (HCV, 64%), followed by

Hepatitis B (HBV, 22%) HDV (3%) and HBV/HCV co-infection (2%).


Chronic Viral (Primary and Secondary)Adults by Era

13%12%

75%

1986 - 1996

8%

39%53%

2007 - 2016

HBV (n = 129)

HCV (n = 372)

Non Viral (n = 755)

12%

31%57%

1997 - 2006

The number of patients requiring transplantation due to HCV has steadily increased over the three

time periods, whereas the number of patients requiring transplantation for HBV has now

decreased.



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1986 - 1996 1997 - 2006 2007 - 2014 2015 2016

Non Viral (n = 755) HBV (n = 129) HCV (n = 372)

% Adults with Chronic HBV or HCV(Primary and Secondary)

Chronic HCV infection comprises 29.6% of adults transplanted.

Fulminant Hepatic Failure as Primary Indication Treated by Liver Transplantation


Fulminant Hepatic Failure As Primary Indication Treated by Liver Transplantation

Aetiology No of Patients No of TxOutcome

Alive Dead

Idiopathic 53 58 34 19

Drug Induced 25 27 16 9

Wilson’s Disease 14 16 12 2

Viral Hepatitis

Hep B 33 35 20 13

Hep C 1 1 1 0

Hep A 3 3 0 3

Hep E 1 1 0 1

Autoimmune Hepatitis 6 7 4 2

Budd-Chiari 1 1 0 1

Other 13 15 9 4

Totals 150 164 96 (64% pts) 54 (36% pts)


HCC and Associated Disease


HCC and Associated DiseaseAdults by Era

HCC Only10%

HBV40%

HCV*30%

Other20%

1986 - 1996

* HCV includes 1 case of HBV,HCV

NASH/NAFLD

7%

HBV25%

HCV *50%

Alcoholic Cirrhosis

14%

Other8%

1997 - 2006

* HCV includes 3 cases of HBV,HCV


HCC and Associated DiseaseAdults by Era

HCC Only1%

NASH/NAFLD

6%

HBV *16%

HCV48%

Alcoholic Cirrhosis

22%

Other8%

2007 - 2011

* HBV includes 1 case of HDV

NASH/NAFLD

11%

HBV *13%

HCV **43%

Alcholic Cirrhosis

27%

Other6%

2012 - 2016

* HBV includes 2 cases of HDV** HCV includes 2 cases of HBV,HCV


NASH/NAFLD by Era


NASH/NAFLD (Primary and Secondary)Adults by Era

NASH/NAFLD

2%

Other98%

1997 - 2006

NASH/NAFLD

0%

Other100%

1986 - 1996


NASH/NAFLD (Primary and Secondary)Adults by Era

NASH/NAFLD

5%

Other94%

2007 - 2011

NASH/NAFLD

10%

Other86%

2012 - 2016


Indication For Secondary Transplantation


2

913

47

21

5

4

6

6

11

16

31

2

7 81

5

5

13

11 1

4

3

0

5

10

15

20

25

30

35

40

0 - 7 days 8 - 30 days 1 - 6 months 6 months - 1 year

1 - 5 years > 5 years

Time to Secondary Transplant

Other

Biliary Strictures

Viral Recurrence

PNF

Rejection

Vascular

Indication for Secondary Transplantation(n = 141)

Primary non function (PNF) is the major indication for re-transplantation in the first 7 days.

Rejection and vascular indications are prominent indications for re-transplantation in all other

time periods.


50.0%

54.3%

47.1%49.1%

67.9%

51.7% 52.4%

0%

10%

20%

30%

40%

50%

60%

70%

1986 - 1990 1991 - 1995 1996 - 2000 2001 - 2005 2006 - 2010 2011 - 2015 2016

Percentage of Children Transplanted for Biliary Atr esia(n = 154; 53.8% of all Children)


PERIOPERATIVE DATA


Mean/Median Hospital Stay


9

5 56

5

34

3 3

5 5

23 3 3

7

2 3 3 4

6

43 3

7 6 75

6 68

36

32

44

49

42

32

38

24 24

40

26

32

42

25 2526

24

21

18

23

20

15

1918

1719

18

14

17

12

16

0

5

10

15

20

25

30

35

40

45

50

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

ICU (Mean)

Ward (Mean)

ICU (Median)

Ward (Median)

Hospital Stay (Mean & Median Days)Adults Only

Red Cell Usage


133 133

58

1610

4

0

20

40

60

80

100

120

140

1986 - 1996 1997 - 2006 2007 - 2016

Red Cell Usage (Max)

Red Cell Usage (Median)

Red Cell Usage(Units of Packed Cells)

Graft Ischaemic Time, Operation Duration and Red Cell Utilisation


Graft Ischaemic Time, Operation DurationAnd Red Cell Utilisation

1986 – 1996 1997 – 2006 2007 – 2016

Mean Graft Ischaemic Time 9 hr 20 min 9 hr 12 min 8 hr 03 min

Mean Operation Time 7 hr 45 min 7 hr 15 min 7 hr 16 min

Mean Cold Ischaemic Time 9 hr 21 min 8 hr 18 min 7 hr 13 min

No. Of Packed Cells Utilised1 – 133

Mean = 21.7;

Median = 16

0 – 133

Mean = 14.0;

Median = 11

0 – 58

Mean = 6.3;

Median = 4


OUTCOME DATA


Patient Survival


025

5075

100

% S

urvi

ving

0 5 10 15 20 25 30Years Post Transplant

Overall Patient Survival 1986 - 2016Adults and Children

1yr 5yr 10yr 15yr 20yr 25yr 30yr

No at risk 1270 874 562 311 156 62 3

Actuarial Survival % 88 79 70 62 53 44 41

n = 1542


025

5075

100

% S

urvi

ving

0 6 1812 24Months Post Transplant

Patient Survival 2015 - 2016Adults and Children

n = 191

6m 12m 18m

No at risk 135 89 43

Actuarial Survival % 95 93 92



025

5075

100

% S

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ving

0 5 10 15 20 25Years Post Transplant

Patient Survival 1986 – 2016Adults vs Children


ChildNo at risk 235 179 126 76 44 24 2


Adult No at risk 1035 695 436 235 112 38 1


Child (n = 286)

Adult (n = 1256)

p < .01


025

5075

100

% S

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ving


Patient Survival 2015 - 2016Adults vs Children

Child (n = 39)

Adult (n = 152)

p = ns

6m 12m 18m

ChildNo at risk 25 20 10


Adult No at risk 110 72 33



Children


025

5075

100

% S

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ving


Children – Weight vs OutcomePrimary Grafts

<10kg (n = 126)

>10kg (n = 16)

p = ns


<10kgNo at risk 100 74 45 23 13 6 2


>10kgNo at risk 135 105 81 53 31 18

Actuarial Survival % 92 90 86 83 77 63


025

5075

100

% S

urvi

ving


Children – Type of Transplant vs OutcomePrimary Grafts

Split (n = 116)

Whole (n = 77)

Reduced (n = 93)

p < .01


SplitNo at risk 97 60 31


WholeNo at risk 66 55 48 38 20 8 1


ReducedNo at risk 72 64 49 38 24 16 1




025

5075

100

% S

urvi

ving


Children – Donor TypePrimary Grafts

Split (n = 114)

Whole (n = 77)

Live (n = 16)

Reduced (n = 79)

p < .01




WholeNo at risk 66 55 48 38 20 8 1


LiveNo at risk 12 3

Actuarial Survival % 81 81

ReducedNo at risk 61 54 47 38 24 16 1



025

5075

100

% S

urvi

ving


Fulminant Disease vs OutcomeAdults vs Children

Child (n = 31)

Adult (n = 119)

p = ns

1yr 5yr 10yr 15yr 20yr 25yr

ChildNo at risk 26 20 15 8 6 3


Adult No at risk 86 67 45 27 15 6



Primary Disease and Outcome


025

5075

100

% S

urvi

ving


Primary Disease vs OutcomeAdults

Malignancy (n = 137)

Metabolic (n = 77)

PBC (n = 74)

PSC (n = 126)

Alcoholic (n = 158)

CC (n = 29)

p < . 01


025

5075

100

% S

urvi

ving


Primary Disease vs OutcomeChildren

CC (n = ?)

BA (n = 154)

CAH (n = 5)

FHF (n = 31)

Metabolic (n = 62)

Malignancy (n = 9)

p = ns


Status at Transplant vs Patient Outcome


025

5075

100

% S

urvi

ving


Status vs OutcomeAdults and Children – Primary Grafts

At home (n = 690)

ICU (n = 149)

Hosp.

Bound(n = 267)

Oc.

Inpatient(n = 436)

p < .01


Status vs OutcomeAdults and Children – Primary Grafts


At Home

(n = 690)

No at risk 595 396 253 124 52 25 2


ICU

(n = 149)

No at risk 110 76 51 30 21 9


Hos. Bound

(n = 267)

No at risk 202 129 69 44 25 10 1


Oc. Inpatient

(n = 436)

No at risk 363 273 189 113 61 20




025

5075

100

% S

urvi

ving


Chronic Viral, Autoimmune Disease vs OutcomePrimary Grafts

HBV (n = 83)

AI (n = 56)

HCV (n = 292)

B, C (n = 9)

p = ns


Chronic Viral, Autoimmune Disease vs OutcomePrimary Grafts


HBV

(n = 83)

No at risk 67 48 40 28 13 4


AI

(n = 56)

No at risk 50 37 28 20 17 6


HCV

(n = 292)

No at risk 241 145 75 31 7 3


B, C

(n = 9)

No at risk 9 9 9 7 3

Actuarial Survival % 100 100 100 100 67


Chronic HBV Outcomes


025

5075

100

% S

urvi

ving


Chronic HBV Before and After Prophylaxis Protocol*Primary and Secondary Indication

* Oral nucleos(t)ide therapy + low dose monthly IMI HBIG

Post

23/2/1996(n = 110)

Pre

23/2/1996(n = 32)

p = ns


Post

23/2/1996

No at risk 98 65 45 25 3


Pre

23/2/1996

No at risk 23 20 19 17 15 4



025

5075

100

% S

urvi

ving


Chronic HBV (Primary and Secondary) vs Era

2007 – 2016 (n = 48)

1997 – 2006 (n = 56)

1986 – 1996 (n = 38)

p = ns


2007 - 2016No at risk 43 17


1997 - 2006No at risk 49 45 42 22

Actuarial Survival % 88 79 75 64

1986 - 1996No at risk 29 24 22 20 18 4



Chronic HCV Outcomes


025

5075

100

% S

urvi

ving


Chronic HCV (Primary and Secondary) vs Era

2007 – 2016 (n = 220)

1997 – 2006 (n = 133)

1986 – 1996 (n = 35)

p = ns


2007 - 2016No at risk 177 72


1997 - 2006No at risk 119 99 83 24


1986 - 1996No at risk 35 29 23 18 13 3



025

5075

100

% S

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ving


Chronic HCV Primary vs Secondary IndicationPrimary Graft Survival

Secondary (n = 84)

Primary (n = 301)

p = ns


SecondaryNo at risk 73 45 20 9 4 1


PrimaryNo at risk 250 154 84 36 10 3




025

5075

100

% S

urvi

ving


HCV vs Donor Age vs Primary Graft OutcomeAdults (n = 388)

> 60 (n = 62)

<30 (n = 92)

30 - 50 (n = 149)

50 - 60 (n = 85)

p = ns


HCV vs Donor Age vs Primary Graft OutcomeAdults (n = 388)


>60

(n = 62)

No at risk 47 26 14 4 2


<30

(n = 92)

No at risk 78 51 35 18 5 4


30 - 50

(n = 149)

No at risk 121 76 38 14 4 1


50 - 60

(n = 85)

No at risk 71 36 14 4 3




025

5075

100

% S

urvi

ving


Non HCV vs Donor Age vs Primary Graft OutcomeAdults (n = 868)

> 60 (n = 181)

< 30 (n = 247)

30 - 50 (n = 281)

50 - 60 (n = 159)

p = ns


Non HCV vs Donor Age vs Primary Graft OutcomeAdults (n = 868)


>60

(n = 181)

No at risk 143 77 32 14 4 2


<30

(n = 247)

No at risk 194 159 115 83 45 19 1


30 - 50

(n = 281)

No at risk 230 162 111 59 30 11


50 - 60

(n = 159)

No at risk 119 77 54 27 16 2



Donor Age vs Primary Graft Outcome


025

5075

100

% S

urvi

ving



> 80 (n = 9)

61 - 70 (n = 151)

< 30 (n = 547)

71 – 80 (n = 61)

31 – 50 (n = 521)

51 – 60 (n = 253)

p = ns




> 80

(n = 9)

No at risk 8 2


61 – 70

(n = 151)

No at risk 119 68 30 13 7 3


< 30

(n = 547)

No at risk 431 322 230 154 80 36 2


71 - 80

(n = 61)

No at risk 48 23 10 5


31 - 50

(n = 521)

No at risk 423 291 182 88 41 14 1


51 - 60

(n = 253)

No at risk 195 120 63 32 15 3



Steatosis vs Graft Outcome (Adults)


025

5075

100

% S

urvi

ving

0 5 10 15Years Post Transplant

Macro Steatosis vs Primary Graft Outcome (Adults)2001 - 2016

S1 Ma/Mi (n = 74)

S2 Ma/Mi (n = 22)

S0 (n = 434)

S3 Ma/Mi (n = 6)

p = ns

1yr 5yr 10yr 15yr

S1 Ma/MiNo at risk 54 20




S0No at risk 340 146 42 6





025

5075

100

% S

urvi

ving


Micro Steatosis vs Primary Graft Outcome (Adults)2001 - 2016

S3 Mi (n = 30)

S1 Mi (n = 94)

S2 Mi (n = 29)

S0 (n = 434)

p = ns

1yr 5yr 10yr 15yr

S3 MiNo at risk 30 26 14 4






S0No at risk 340 146 42 6



Graft Survival


025

5075

100

% S

urvi

ving


Graft Survival by Graft NoAdults and Children

Tertiary (n = 16)

Primary (n = 1542)

Secondary (n = 117)

p < .01


Graft Survival by Graft NoAdults and Children


Tertiary

(n = 16)

No at risk 10 10 3 2 2


Primary

(n = 1542)

No at risk 1224 826 515 290 140 56 3


Secondary

(n = 117)

No at risk 70 46 26 14 7 4




025

5075

100

% S

urvi

ving


Graft Survival by Graft NoAdults and Children 2015 – 2016

Tertiary (n = 2)

Secondary (n = 18)

Primary (n = 191)

p = ns

6m 12m 18m

TertiaryNo at risk 2 2 1


SecondaryNo at risk 10 4


PrimaryNo at risk 131 87 42



025

5075

100

% S

urvi

ving


Graft SurvivalAdults vs Children 2015 - 2016

Adult (n = 164)

Child (n = 47)

p = ns

6m 12m 18m

AdultNo at risk 114 74 33


ChildNo at risk 29 19 10




025

5075

100

% S

urvi

ving


Primary Graft Survival by EraAdults and Children

2007 – 2016 (n = 700)

1997 – 2006 (n = 493)

1986 - 1996 (n = 349)

p < .01


2007 - 2016No at risk 548 227


1997 - 2006No at risk 424 377 328 122


1986 - 1996No at risk 252 222 187 168 140 56 3



025

5075

100

% S

urvi

ving


Primary Graft Survival by EraAdults

2007 – 2016 (n = 574)

1997 – 2006 (n = 402)

1986 – 1996 (n = 280)

p < .01


2007 - 2016No at risk 454 184


1997 - 2006No at risk 344 302 261 96


1986 - 1996No at risk 205 178 145 127 102 35 1




025

5075

100

% S

urvi

ving


Primary Graft Survival by EraChildren

2007 – 2016 (n = 126)

1997 – 2006 (n = 91)

1986 – 1996 (n = 69)

p < .01


2007 - 2016No at risk 94 43


1997 - 2006No at risk 80 76 67 26


1986 - 1996No at risk 47 45 44 42 38 21 2


Split vs Reduced vs Whole Grafts


025

5075

100

% S

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ving


Split vs Whole Grafts (Adults)Primary Graft Survival 2002 – 2016

Split (n = 122)

Whole (n = 673)

p = ns

1yr 5yr 10yr



WholeNo at risk 550 300 120




025

5075

100

% S

urvi

ving


Split vs Reduced vs Whole Grafts (Children)Primary Graft Survival 2002 – 2016

Whole (n = 32)

Reduced (n = 32)

Split (n = 115)

p = ns

1yr 5yr 10yr



ReducedNo at risk 27 23 8





025

5075

100

% S

urvi

ving


Split vs Reduced vs Whole Grafts (Children)Patient Survival 2002 – 2016

Whole (n = 32)

Split (n = 115)

Reduced (n = 32)

p = ns

1yr 5yr 10yr





ReducedNo at risk 27 23 10



Auxiliary Transplant Survival


025

5075

100

% S

urvi

ving

0 2 4 6 8 10 12 14Years Post Transplant

Auxiliary Transplant (Children)Patient and Graft Survival

Graft

Survival(n = 3)

Patient

Survival(n = 3)

p = ns

1yr 5yr 10yr

GraftNo at risk 3 1 1


PatientNo at risk 2 1 1



Cause of Death

Cause of Death

Graft Failure 130 (26.6%)

Rejection: Chronic 28

Rejection: Acute 10

Recurrent disease

Hepatitis C 40

Biliary Complications 10

Hepatitis B 11

Vascular 15

PNF 4

NASH 3

Other 9

Malignancy 95 (19.5%)

De Novo 61

Recurrent disease 33

Transferred from donor 1

Sepsis 89 (18.2%)

Cardiovascular 33 (6.8%)

Cerebral 33 (6.8%)

Respiratory 27 (5.5%)

Multi-organ Failure 12 (2.5%)

Operative 11 (2.3%)

Gastrointestinal 10 (2.0%)

Vascular 8 (1.6%)

Renal Failure 5 (1.0%)

GVHD 4 (0.8%)

Other 31 (6.3%)

TOTAL 488

(31.6% of all patients)



Cause of Death(n = 488)

Operative2%

Sepsis18%

Cardiovascular7%

Cerebral7%

Malignancy - De Novo13%

Malignancy -Recurrent

7%

Respiratory5%

Rejection8%

GI2%

Miscellaneous12%

Recurrent Disease12%

Biliary Complications2% PNF

1%Vascular (pt)

3%

Other1%

Graft failure27%

488 patients, or 33.7% of all patients transplanted, have died. Of these, 89 (18%) have died due to

sepsis and 130 (27%) from graft failure.

Of the 130 cases of death due to graft failure, 38 (29%) patients lost grafts due to rejection, 58

(45%) from recurrent disease and 4 (3%) from primary non function (PNF).


Cause of Death(n = 488)

Operative3%

Sepsis18%

Cardiovas7%

Cerebral6%

Malignancy20%

Respiratory5%

GI2%

Misc12%

Graft Failure27%

Adults (n = 436)

Sepsis21%

Cardiovas2%

Cerebral15%

Malignancy12%

Respiratory10%

GI2%

Misc17%

Graft Failure21%

Children (n = 52)

The majority of adult deaths were due to Graft Failure (119 or 27%), Malignancy (89 or 20%) and

Sepsis (78 or 18%). The majority of child deaths were due to Graft Failure (11 or 21%), Sepsis (11

or 21%) and Cerebrovascular accident (8 or 15%).



7 7 7 6 32

152

2

4

1

12

1

4

1

1

46

29

20

12

9 3

23

15

108

13

262

1

17

12

7

6 6

3

8

3

10

3

3

4 1

1

41

1114

4 4

4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 year 1 - 5 years 5 - 10 years 10 - 15 years

15 - 20 years

>20 years

Sepsis

Respiratory

Operative

Miscellaneous

Recurrent Malignancy

De Novo Malignancy

Graft Failure

Gastrointestinal

Cerebral

Cardiovascular

Cause of Death by Time - Adults(n = 436; 37.0% of adults)


18

72

11

1

1

2

1

1

7

2

2

1

1

1

6 1

2

1

11

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


15 - 20 years

>20 years

Gastrointestinal

Sepsis

Respiratory

Miscellaneous


De Novo Malignancy

Graft Failure

Cerebral

Cardiovascular

Cause of Death by Time - Children(n = 52; 19.6% of children)



11 15 6

15 82

52 47

20

2022

15

109

13

18

18 1510

57

3728

13

6 3 24 4 1

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1986 - 1996 1997 - 2006 2007 - 2016

GI

Operative

Sepsis

Respiratory

Miscellaneous


De Novo Malignancy

Graft Failure

Cerebral

Cardiovascular

Cause of Death by Transplant Era - Adults(n = 436; 37.0% of adults)


1

7

1

4

6 1

5

1

4

2

3

2

3

73

11

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1986 - 1996 1997 - 2006 2007 - 2016

GI

Sepsis

Respiratory

Miscellaneous


De Novo Malignancy

Graft Failure

Cerebral

Cardiovascular

Cause of Death by Transplant Era - Children(n = 52; 19.6% of children)



Cause of Death – HCV Recipients(n = 129)

Cardiovascular5%

Cerebrovascular1%

Gastrointestinal1%

Other Graft Failure5%

Malignancy - De Novo12%

Malignancy -Persistent

14%

Operative4%

Sepsis14% Respiratory

1%

Recurrent HCV30%

Other 13%


Cause of Graft Failure

Cause of Graft Failure Rejection 74 (11.9%)

Acute 15

Chronic 52

ABO incompatibility 6

Subacute 1

Vascular complications 53 (8.5%)

Hepatic artery thrombosis 38

Portal vein thrombosis 6

Graft infarction 2

Dissection in donor 1

Donor graft damage 1

Graft compression 1

Hepatic vein stenosis 1

PVT/HAT 1

Rupture 1

Vena Cava obstruction 1

Recurrent disease 103 (16.6%)

Hep C 47

Malignancy 29

Hep B 14

PSC 6

NASH 3

Alcohol 1

Cryptogenic cirrhosis 1

Primary non function 23 (3.7%)

Graft infarction 8

Severe steatosis 2

Antibody mediated rejection 1

Arterial thrombosis 1

Blood loss 1

HA occlusion 1

Preservation injury 1

Profound hypotension 1

Vena 1

Other 6

Patient deaths 306 (49.3%)

Sepsis 80

Malignancy 65

Cerebral 33

Cardiovascular 27

Respiratory failure 26

Intraoperative 15

GI haemorrhage 8

GVHD 4

Pancreatitis 3

Other 45

Biliary complications 35 (5.6%)

Biliary strictures 24

Other 11

Other 27 (4.3%)

TOTAL 621 (37.1%) of all grafts



Cause of Graft Failure(n = 621)

Rejection12%

PNF4%

Vascular9%

Recurrent Disease17%

Other4%

GVHD1%

Malignancy10%

Other8%

Cardiac4% Intraop

2%Respiratory4%

Cerebral5%

Sepsis13%

GI1%

Biliary6%

Pancreatitis0.5%

Other48%

621 of 1675 grafts (37.1%) have failed.

306 grafts (51%) were lost due to patient deaths, 103 (17%) due to disease recurrence and 74

(12%) due to rejection.

Sepsis was the most significant cause of patient death (80 patients), followed by malignancy (65

patients) and cerebral catastrophe (32 patients).


Cause of Graft Failure(n = 621)

Rejection10%

PNF3%

Patient Death53%

Vascular6%

Recurrent Disease

20%

Other 4%

Biliary4%

Adults (n = 518)

Rejection22%

PNF7%

Patient Death32%

Vascular18%

Other 7%

Biliary14%

Children (n = 103)

Patient death was the most significant cause of graft failure, followed by rejection.



5 3 5 4 22

5 73

3

2

16

106

54

50

32 21

10

26 46

20

7

428

107

1

4

127

5 1 1

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


15 - 20 years

>20 years

Vascular

Rejection

Recurrent Disease

Pt Death

PNF

Other

Biliary

Cause of Graft Failure by Time - Adults(n = 518; 38.6% of adult grafts)


22

7 3

3

1

2

17

25

2

2

1

1

2

8

7

5 1

1

114 4

1

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


15 - 20 years

>20 years

Vascular

Rejection

Pt Death

PNF

Other

Biliary

Cause of Graft Failure by Time - Children(n = 103; 30.9% of child grafts)



11 8 2

4 4 122 6

8

109105

59

37

42 24

3311 7

11 14 9

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1986 - 1996 1997 - 2006 2007 - 2016

Vascular

Rejection

Recurrent Disease

Pt Death

PNF

Other

Biliary

Cause of Graft Failure by Transplant Era - Adults(n = 518; 38.6% of adult grafts)


3

6 53

1

3

4

1

2

21

6

6

10

9

4

6

9

4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1986 - 1996 1997 - 2006 2007 - 2016

Vascular

Rejection

Pt Death

PNF

Other

Biliary

Cause of Graft Failure by Transplant Era - Children(n = 103; 30.9% of child grafts)


CANCER AND

TRANSPLANTATION


Malignancy at Transplantation


1 2 1 1 2 13

7

119

11

7 79

1514

11

18

12

18

15

25

19 20

2322

26

1

1

11 2 1

1

1

11

1 2

1

1 2

2

2

1

3

1

1

1

1

1

1

2

2

1

1

0

5

10

15

20

25

3019

87

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Cholangiocarcinoma (n = 16)

Miscellaneous (n = 20)

Hepatoblastoma (n = 2)

HCC (n = 310)

Malignancy at Transplantation(n = 337 Pts/348 Ca; 23.3% of patients)


1 1 1 1 13

2 1 1

5

8 7 75 5

8

14

11 10

14

9

16

13

20

13

17 20

17

22

1 1

2

2

3

24

2 2

1

1

3

3

2

2

2

5

6

2

3

5

3

0

5

10

15

20

25

30

Pre

199

0

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Unknown Pre Tx: Found in Explant (n = 57)

Known Pre Tx: Confirmed at Explant (n = 248)

Chemo or Injection Pre Tx: No Tumour at Explant (n = 5)

HCC at Transplantation(n = 310)



Cancer in Liver Transplant Recipients1986 - 2016

At Transplant (1544 patients) Patients (n,%)

Liver cancer as primary diagnosis 146 9.5%

Liver cancer as secondary diagnosis 193 12.5%

No. of Patients with a cancer diagnosis at transplant 339 22.0%

Post Transplant

Recurrent liver cancer 38 2.5% of all pts, 11.2% of cancer at tx pts

De novo non-skin cancer 123 8.0% of all pts, 36.3% of cancer at tx pts

De novo skin cancer 208 13.5% of all pts, 61.4 % of cancer at tx pts

No. of Patients with a post transplant cancer 369 23.9% of all pts

Patients with multiple cancers 208 13.5% of all pts

Pre transplant cancer developed de novo cancer 62 18.3% of cancer at tx pts

Transferred from donor 4

Developed non-skin cancer within 90 days 1


025

5075

100

% S

urvi

ving


HCC vs EraPrimary and Secondary Indication

2007 – 2016 (n = 198)

1997 – 2006 (n = 101)

1986 – 1996 (n = 11)

p = ns


2007 - 2016No at risk 161 62


1997 - 2006No at risk 87 71 61 21


1986 - 1996No at risk 11 8 8 5 3




025

5075

100

% S

urvi

ving


Benign Disease vs Malignancy

Benign (n = 1205)

Malignant (n = 337)

p < .05


BenignNo at risk 992 723 490 282 150 90 3


MalignantNo at risk 278 151 72 29 6 2



025

5075

100

% S

urvi

ving


Primary and Secondary HCC vs No HCC

No HCC (n = 1351)

With HCC (n = 324)

p = ns


No HCCNo at risk 1088 790 529 3041 163 64 3


With HCCNo at risk 266 146 68 25 3



De Novo Non Skin Cancer Post Transplant


De Novo Cancer (Excluding Skin)n = 123 Pts, 133 Ca; 8.5% pts transplanted

No Male Female

Age of

patients

(years)

Time to diagnosis

(months)

Died of This

Cancer

Died

Other

Alimentary 48 38 1013 - 78

(m = 59)

6 - 266

(m = 74)24 50% 8

Lymphoma (inc PTLD) 31 18 131 - 70

(m = 49)

4 -281

(m = 104)9 29% 6

Genitourinary 16 13 321 - 74

(m = 59)

2 - 228

(m = 1163)2 13% 5

Respiratory 15 12 329 - 71

(m = 55)

7 - 193

(m = 81)8 53% 0

Breast 9 0 930 - 60

(m = 44)

50 - 252

(m = 135)6 67% 1

Endocrine 8 2 636 - 70

(m = 48)

14 - 144

(m = 56)2 25% 0

CNS 3 1 266 - 79

(m = 75)

14 - 210

(m = 93)2 67% 0

Bone 1 0 1 69 69 1 100% 0

Fibrous Histiocytoma 1 0 1 62 120 0 0

Kaposi’s 1 1 0 32 48 0 1

Total 133 85 481 - 80

(m = 56)

0 - 281

(m = 83)72 54% 21

NB: m = median


De Novo Cancer (Excluding Skin)n = 123 Pts, 133 Ca; 8.5% pts transplanted

Breast7%

CNS2%

Endocrine6%

Genitourinary12%

Kaposi's Sarcoma

1%

Lymphoma23%

Respiratory11%

Lower GI25%

Pancreas4%

Upper GI7%

Fibrous Histiocytoma1%Bone

1%

Alimentary40%


Pre Transplant Liver Disease and De Novo Non Skin Cancer


Pre Transplant Liver Disease andDe Novo Cancer (Excluding Skin)

n = 133

7

7

5

4

3

1 1 1

0

1

2

3

4

5

6

7

PSC + Autoimmune29/133; 22% of all De Novo

4

2 2 2 2

1 1

0

1

2

3

4

5

6

7

HBV15/133; 133% of all De Novo


Pre Transplant Liver Disease andDe Novo Cancer (Excluding Skin)

n = 133

6 6

4

7

2 2

1 1

0

1

2

3

4

5

6

7

8

HCV29/133; 22% of all De Novo

8

5 5

2

3

1 1

0

1

2

3

4

5

6

7

8

Alcohol25/133; 19% of all De Novo



12 129

5

1

7 6

1

3

4

3

4

2

3

3

1

5

4

1

0

5

10

15

20

25

30

PSC + AI HCV ALD HBV PBC

CNS (n = 1)

Bone (n = 1)

Fibrous Histiocytoma (n = 1)

Respiratory (n = 9)

Kaposi's Sarcoma (n = 1)

Genitourinary (n = 12)

Endocrine (n = 7)

Lymphoma (n = 17)

Alimentary (n = 39)

Primary Liver Disease andDe Novo Cancer (Excluding Skin)


5

16

14

13

1

3

5

1 1 1

4

3

11

2 2

3

8

1

3

6

10

12

1

5

3

6

1

0

2

4

6

8

10

12

14

16

0 - 6 months 6 - 12 months 1 - 5 years 5 - 10 years >10 years

Alimentary (n = 48)

Breast (n = 9)

CNS (n = 3)

Endocrine (n = 8)

Genitourinary (n = 16)

Kaposi's Sarcoma (n = 1)

Lymphoma (n = 31)

Respiratory (n = 15)

Fibrous Histiocytoma (n = 1)

Bone (n = ?)

Time to DiagnosisDe Novo Cancer (Excluding Skin)


Cumulative Risk of Diagnosis of Cancer


Cumulative Risk of Diagnosis of CancerFollowing Liver Transplantation 1986 – 2016

0

20

40

60

80

100

0 5 10 15 20 25Years Post Tx

Any Cancer

Skin

De Novo Non Skin

Age Matched Gen. Pop

Documents

Australian National Liver Transplantation Unit€¦ · 1675 liver transplants on 1544 patients have been performed at ANLTU. In 2016, 98 new, 14 secondary and 1 tertiary orthotopic