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Liver Transplantation
at
Australian National Liver Transplantation Unit
Data to 31 December 2008
The Australian National Liver Transplantation Unit, Royal Prince Alfreed Hospital,Sydney, Australia is a combined facility of the Sydney South West Area Health Service, University of Sydney and The Children’s Hospital, Westmead.
Data to 31/12/2008 © copyright ANLTU 1
Contents Preface .................................................................................................... 2 Summary................................................................................................. 3
ASSESSMENT INFORMATION ................................................................................................... 4 Assessments and Transplant Operations....................................................................................... 5 Allocation of Assessed Adults/Children .......................................................................................... 5 Comparison Over Time Of Patients Assessed .............................................................................. 6 Patients Considered Unsuitable for Transplantation (Adults)......................................................... 7 Waiting List Activity ......................................................................................................................... 7 Patients Withdrawn From Waiting List............................................................................................ 8 Urgent Listings ................................................................................................................................ 8 Age, Sex and Waiting time of Transplant Recipients (Primary Grafts)........................................... 9 Adult Mean Days Waiting for Primary Transplantation vs ABO (2000 – 2008).............................. 9
DONOR INFORMATION............................................................................................................. 10 Living Donor Procedures .............................................................................................................. 11 Deceased Donor Offers ................................................................................................................ 11 Deceased Donor Offers Refused 2008 ........................................................................................ 12 Allocation of Accepted and Used Deceased Donor Offer Livers 2008......................................... 12 Deceased Donor Age by Era (Median)......................................................................................... 13 Deceased Donor Cause of Death................................................................................................. 13 Adult vs Paediatric Donors by Year .............................................................................................. 14 Donors over 50 years.................................................................................................................... 15 Graft Steatosis .............................................................................................................................. 15
RECIPIENT DEMOGRAPHICS .................................................................................................. 16 Patient age at transplant ............................................................................................................... 17 Primary hepatic disease – All patients.......................................................................................... 17 Primary Disease – Adults, Children .............................................................................................. 18 Chronic Viral Hepatitis (Primary and Secondary) in Adult Patients by Era .................................. 19 Fulminant Hepatic Failure Treated by Liver Transplantation........................................................ 20 Indication For Secondary Transplantation.................................................................................... 21
PERIOPERATIVE DATA............................................................................................................. 22 Mean/Median Hospital Stay.......................................................................................................... 23 Red Cell Usage............................................................................................................................. 23 Graft Ischaemic Time, Operation Duration and Red Cell Utilisation ............................................ 23
OUTCOME DATA ....................................................................................................................... 24 Patient Survival ............................................................................................................................. 25 Children vs Weight........................................................................................................................ 26 Paediatric Transplants .................................................................................................................. 26 Primary Disease and Outcome..................................................................................................... 27 Fulminant Disease and Outcome ................................................................................................. 29 Status at Transplant vs Pt Outcome ............................................................................................. 30 Viral Disease vs Outcome ............................................................................................................ 30 Chronic HBV Outcomes................................................................................................................ 31 Chronic HCV Outcomes ............................................................................................................... 31 Donor Age vs Primary Graft Outcome.......................................................................................... 34 Steatosis vs Graft Outcome (Adults) ............................................................................................ 35 Graft Survival by Era..................................................................................................................... 36 Split vs Reduced vs Whole Graft Outcome .................................................................................. 37 Graft Outcome .............................................................................................................................. 38 Survival of Special Groups............................................................................................................ 39 Cause of Death ............................................................................................................................. 40 Cause of Graft Failure................................................................................................................... 43 Malignancy at Transplantation...................................................................................................... 46
Cancer after transplantation........................................................................................................ 47 De novo Non Skin Cancer Post Transplant.................................................................................. 48
Data to 31/12/2008 © copyright ANLTU 2
Preface In 2008, 56 new and 3 secondary orthotopic liver transplant procedures were performed within the ANLTU (11 – Paediatric; 45 – Adult). 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 staff within Royal Prince Alfred Hospital and Sydney South West Area Health Service who have helped contribute to the success of the program in the past year. This includes Staff in 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 Anaethesia, 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 staff of Department of Anaesthesia, the Intensive Care Unit, Laboratory services staff, Department of Social Work, Department of Nutrition and other medical departments. 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 staff of the Organ Donation Network NSW/ACT organ procurement agency of the ARCBS. Professor Geoff McCaughan Dr Deborah Verran Pamela Dilworth Patrick Tang Carol Tse
Data to 31/12/2008 © copyright ANLTU 3
Summary
There are several key issues to report
1. From January 1986 to December 2008, 1026 liver transplants were performed on 947
patients, of which 769 and 178 recipients were adults and children, respectively.
2. The number of transplants per year continues to be related to the deceased donor rate.
3. In 2008, three (3) paediatric live donor liver transplants were performed.
4. In 2008, 32 patients (23%), the highest number ever, on the waiting list were
subsequently withdrawn due to advanced and/or extra-hepatic disease. Five (3.5%)
patients improved whilst on the waiting list. During this period, there were 59 liver
transplantation operations, in which 56 patients had primary grafts.
5. The movement of patients on and off the waiting list continues to be dynamic.
6. The average waiting time for adults in all blood groups remains variable depending on
blood group.
7. HCV infection was present in 26% of adults recipients since 1986.
8. The overall patient survival rates over the past 2 years was 97% at one year.
8 11
19 21 24
3643
3831 33
3944 46
31
42
28
4741
65
44 4540
46
43
6
13 8
10
10
8
47
73
6
10
9
11
14
8
13
13 1014
13
0
10
20
30
40
50
60
70
80
90
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
1026 Liver Transplants
Children (n=204)Adults (n=822)
Australian National Liver Transplantation Unit
Data to 31/12/2008 © copyright ANLTU 4
ASSESSMENT INFORMATION
ASSESSMENT INFORMATION
Data to 31/12/2008 © copyright ANLTU 5
Assessments and Transplant Operations
10
43
68 6872
80
94
102
74
98
68
88
96100
110105 105
99
84
106
116
86
7477
11 11
2430 30
4549
41
33 33
42 4450
37
47
37
56
45
74
5450 49
56
0
20
40
60
80
100
120
140
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Assessed (n=2023)Transplanted (n=947)
Assessments and Transplant Operations
Allocation of Assessed Adults/Children
Deferred7%
Accepted84%
Unsuitable9%
Allocation of Assessed Childrenn = 268
Deferred16%
Died Pre-list1%
Under Assessment
1%
Unsuitable25%
Accepted57%
Allocation of Assessed Adultsn = 1755
ASSESSMENT INFORMATION
Data to 31/12/2008 © copyright ANLTU 6
Comparison Over Time Of Patients Assessed Comparison Over Time of Patients Assessed
Accepted49%
Deferred17%
Unsuitable34%
Died Pre-List0%
Adults(n=505)
Accepted69%
Deferred12%
Unsuitable19%
Children(n=106)
1986 - 1993
ACCEPTED53%DEFERRED
21%
UNSUITABLE26%
Died Pre-List0%
ACCEPTED91%
DEFERRED6%
UNSUITABLE3%
Adults(n=692)
Children(n=78)
1994 - 2001
UNSUITABLE4%DEFERRED
1%
ACCEPTED95%
UNDER ASSESSMENT
2%DIED PRE-LIST3%UNSUITABLE
14%
DEFERRED9%
ACCEPTED72%
Adults(n=558)
Children(n=84)
2002 - 2008
Adult patient acceptance rate has increased from 53% in the period of 1994 - 2001 to 72% in 2002-2008. Children patient acceptance rate has increased from 91% in the period of 1994 – 2001 to 95% in 2002 -2008.
ASSESSMENT INFORMATION
Data to 31/12/2008 © copyright ANLTU 7
Patients Considered Unsuitable for Transplantation (Adults) Patients Considered Unsuitable for Transplantation
(1755 Adults have been assessed since 1985)
Reason Adults Too Advanced + extrahepatic disease 156 (36%) Tumour (extra-hepatic spread) 68 (16%) Psychological 59 (14%) Good Prognosis 62 (14%) Alcohol 55 (13%) Patient's (parent's) wish 20 (5%) Age 4 (1%) Alternative therapy 7 (2%) Logistics 1 Total 432 (25%)
Waiting List Activity
Waiting List Activity Withdrawn
Year Listed at Start of Year
New Listings
Totalt
Transplanted
Died Pre Tx Tumour
Progressed Other*
Total Withdrawal
Mortality
Improved
Listed at End of Year
n 35 69 104 49 5 8 8 21 3 31
2003 % 47 4.8 7.7 7.7 20 2.9
n 31 101 130 78 7 0 2 12 3 37
2004 % 60 5.4 0 1.5 9 2.3
n 37 83 120 54 10 1 6 17 3 38
2005 % 45 8.3 0.8 5 14 2.5
n 38 83 121 55 6 3 0 9 6 46
2006 % 45 5 2.5 0 7.4 5
n 46 95 141 54 19 2 2 23 2 63
2007 % 38 13 1 1 16 1
n 63 76 139 59 25 2 5 32 5 43
2008 % 42 18 1 3.5 23 3.5
• Advanced and/or extra-hepatic disease
31
37
38
46
63
43
0 10 20 30 40 50 60 70
2003
2004
2005
2006
2007
2008
Patients on Waiting List at end of calendar year
ASSESSMENT INFORMATION
Data to 31/12/2008 © copyright ANLTU 8
Patients Withdrawn From Waiting List
% Patients Withdrawn from Waiting List
20
9
14
7.4
16
23
3
2.3
2.5
5
1
3.5
0
5
10
15
20
25
30
2003 2004 2005 2006 2007 2008
% P
atie
nts
With
draw
n
Withdrawal/Mortality Improved
No of Patients Withdrawnfrom Waiting List
21 2017
9
23
32
3 3
3
6
2
5
0
5
10
15
20
25
30
35
40
2003 2004 2005 2006 2007 2008
Num
ber o
f Pat
ient
s
Withdrawal/Mortality Improved
Urgent Listings Urgent Listings 2008
Number of patients listed as URGENT 9
Transplanted 4
Died on Waiting List 3
Improved - withdrawn 2
ASSESSMENT INFORMATION
Data to 31/12/2008 © copyright ANLTU 9
Age, Sex and Waiting time of Transplant Recipients (Primary Grafts) Age, Sex and Waiting time of Transplant Recipients (Primary Grafts)
Waiting time of Transplant Recipients (Primary Grafts)
52 52 74n= 189 271 309n=
N=178
Median Month: 2.23
Range: 0d – 4y
N=769
Median Month: 1.7
Range: 0d – 5.8y
2002 - 20081994 - 20011986 - 1993
Ran
ge (M
onth
s)
60
40
20
0
Median
2015
105
0
48.10
23.21
14.49
2.232.851.95
Children
2002 - 20081994 - 20011986 - 1993
Ran
ge (M
onth
s)
60
40
20
0
Median
2015
105
0
69.25
29.97
7.804.07
1.510.79
Adults
n=178Median: 2.23mRange: 0-4y
n=769Median: 1.7mRange: 0-5.8y
Age of Transplant Recipients (Primary Grafts)
Children Adults
4.41y
2.18y1.25y
52 52 74n=
n=178Median: 2.25yRange: 0.4 – 14.81y
n=769Median: 49.72yRange: 15.31y – 69.49y
45.41y48.3y
52.11y
189 271 309n=
2002 - 20081994 - 20011986 - 1993
70
60
50
40
30
20
10
2002 - 20081994 - 20011986 - 1993
14
12
10
8
6
4
2
0
Adult Mean Days Waiting for Primary Transplantation vs ABO (2000 – 2008)
0
50
100
150
200
250
300
350
400
450
2000 2001 2002 2003 2004 2005 2006 2007 2008
A AB B O
Adult Mean Days Waiting for Primary Liver Transplantation vs ABO (2000-2008)
Data to 31/12/2008 © copyright ANLTU 10
DONOR INFORMATION
DONOR INFORMATION
Data to 31/12/2008 © copyright ANLTU 11
Living Donor Procedures
Living Donor Procedures
Year Type Total
1990 LRD 1
2002 LRD 1
2003 LUD 1
2004 LRD 1
2006 LRD 2
2007 LRD 3
2008 LRD 3
TOTAL 12
Deceased Donor Offers
Deceased Donor Offers Donor Type State 1986-
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Total
ACT 43 5 4 6 5 6 7 4 2 3 85 NSW 800 62 53 52 47 66 44 48 45 47 1264 NT 11 1 3 1 1 1 2 20 NZ 194 7 2 3 4 5 4 7 2 4 232 QLD 160 3 9 7 9 5 4 2 8 10 217 SA 115 9 11 13 5 13 3 5 6 6 186 TAS 19 3 2 1 3 28 VIC 227 6 6 8 7 8 8 6 5 12 293
BDD
WA 54 7 4 3 4 7 5 4 3 2 93 DCD NSW 6 16 22 Total 1623 100 92 95 82 111 75 79 78 105 2440 Used 522 50 39 57 43 68 52 48 43 49 971
DONOR INFORMATION
Data to 31/12/2008 © copyright ANLTU 12
Deceased Donor Offers Refused 2008
BDD Donor Offers Refused 2008
Refused at Offer
Refused at Hepatectomy
Abnormal LFT’s 2 Known liver disease 1 Logistics 4 Not suitable for designated recipient 10 Offer waived 4 Preservation injury 1 Steatosis 2 8 Unsuitable donor 7 3
TOTAL 30 12
DCD Donor Offers Refused 2008
Refused at Offer
Refused at Hepatectomy
Abnormal LFT’s 2 Did not proceed to hepatectomy 4 Logistics 1 Outside DCD acceptance criteria 6 Perfusion failure 1
TOTAL 12 2
Allocation of Accepted and Used Deceased Donor Offer Livers 2008 Allocation of Accepted and Used Deceased Donor Livers – 2008
1st Recipient Allocation Total
Alternative patient selected due to logistical constraints 1
ECD liver to stable recipient 2
Sickest 29
Split paediatric recipient 7
Split right lobe recipient (size/blood group match) 1
Tumour 1
Urgent Category 1 1
BDD
Urgent Category 2 5 DCD ECD liver to stable recipient 2
Total 49
2nd Recipient Allocation Total BDD Split right lobe recipient (size/blood group match) 7
Total 7
DONOR INFORMATION
Data to 31/12/2008 © copyright ANLTU 13
Deceased Donor Age by Era (Median)
2006-20082001-20051996-20001991-19951986-1990
Don
or A
ge80
60
40
20
0
Deceased Donor Age by Era
116 220 236n= 140259
n=971Median: 37yRange: 0 – 79y
22y
33y
39.5y43y 43y
Deceased Donor Cause of Death
(n=971)
Other11%
Motor Vehicle20%
Suicide4%
Other Trauma12%
Hypoxia/Anoxia4%
Tumour1%
Cerebral48%
Deceased Donor Cause of Death
The majority of donors died due to cerebral haemorrhage (465 or 48%) and motor vehicle accident (199 or 20%).
DONOR INFORMATION
Data to 31/12/2008 © copyright ANLTU 14
4
7
3
104
141
220
8
9
24
64
71
64
25
47
40
12
12
14
44
24
34
0 50 100 150 200 250
1986 - 1993
1994 - 2000
2001 - 2008
Tumour CerebralHypoxia/Anoxia MVA/MBAOther Trauma SuicideOther
Deceased Donor Cause of Death by Era
Deaths due to trauma were 34%, 38% and 26% within the above year groups, respectively. In these same time periods, deaths due to cerebrovascular disease (CVD) were 40%, 45% and 55%.
Adult vs Paediatric Donors by Year
9 10
18
2724
39
47
38
30
35
42 42
47
31
42
34
47
40
65
4947
37
44
3 47 7 7 7 6
85 5 4 5 5
108
5
10
3 3 31
53 21
0
10
20
30
40
50
60
70
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Adult DBDChild DBDAdult DCD
Adults (n=847)Children (n=124)
(Deceased) Adult vs Paediatric Donors By Year
87% of liver donors were adult (>=15yrs) and 13% were children.
DONOR INFORMATION
Data to 31/12/2008 © copyright ANLTU 15
Donors over 50 years
1 2 1 2
68
11
3 36
8 8 97 8
47
16
11
7 8
123
2
13
2
9 6
3 2
4
3
6
8
45
72
1 2 3
5
2
5 1
3
0
5
10
15
20
25
30
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
>70 (n=24)61-70 (n=68)51-60 (n=148)
Deceased Donors over 50 years(n=240)
Donor age ranged from 0 to 79 years, with a mean value of 36 ± 18 years.
Graft Steatosis
8
5
1312
10
16
8
25
7
9
6
15
9
76
13
3
6 6
16
10
1314
21 1
21 1 1
3
1
3
5
8
4
11 1 1 12
0
5
10
15
20
25
30
2001 2002 2003 2004 2005 2006 2007 2008
S0 S1 - Ma/MiS1 - Mi S2 - Ma/MiS2 - Mi S3 - Ma/MiS3 - Mi
Adult Graft Steatosis 2001-2008
Steatosis Scoring: S0 - less than 5% steatosis in biopsy [either macro or micro] S1 Mi- less than 5% Macrovesicular steatosis and 5-29% microvesicular steatosis S2 Mi- less than 5% Macrovesicular steatosis and 30<60%% microvesicular steatosis S3 Mi- less than 5% Macrovesicular steatosis and 60+% microvesicular steatosis 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
Data to 31/12/2008 © copyright ANLTU 16
RECIPIENT DEMOGRAPHICS
RECIPIENT DEMOGRAPHICS
Data to 31/12/2008 © copyright ANLTU 17
Patient age at transplant
22
7752 49 77
166
274
230
0
50
100
150
200
250
300
< 1 1-3 4-15 15-40 40-50 50-60 60-65 >65
Breakdown of Patient Age at Primary Transplantn=947
The modal group was in the age range 51-60 years (29%).
Primary hepatic disease – All patients
HBV7%
B,C1%
AIH4%
HCV15%
Metabolic12%
Fulminant11%
ALD8%
CC3%
PSC9%
PBC6%
Other5%
Biliary Atresia11%
Malignancy8%
Primary Disease – All Patients
The most common indications for transplantation are Chronic Hepatitis C (148,15%), Metabolic disease (110, 12%), Biliary Atresia (103, 11%) and Fulminant Liver Failure (100, 11%).
RECIPIENT DEMOGRAPHICS
Data to 31/12/2008 © copyright ANLTU 18
Primary Disease – Adults, Children
AIH5%
HBV9%
B,C1% Malignancy
9%
Biliary Atresia1%
Other5%
PBC8%
PSC11%
CC3%
ALD10%
Fulminant11%
Metabolic8%
HCV19%
Primary Disease – Adultsn = 769
Hepatitis C was the most common indication of transplantation in adults (148, 19%), followed by Primary Sclerosing Cholangitis (PSC 87, 11%), Fulminant Hepatic Failure (84, 11%), Alcoholic Liver Disease (ALD 74, 10%) and Hepatitis B (64, 9%).
Malignancy3%
Biliary Atresia54%
CC1%
Other5%
Metabolic28%
Fulminant9%
Primary Disease – Childrenn = 178
The most common indication for transplantation in children was Biliary Atresia (97, 54%), followed by Metabolic disease (50, 28%) and Fulminant Hepatic Failure (16, 9%).
RECIPIENT DEMOGRAPHICS
Data to 31/12/2008 © copyright ANLTU 19
Chronic Viral and Auto-immune Hepatitis
B,C3% HBV
25%
HCV56%
CVH83%AI
16%
n = 265 (34.5% of Adults)
Autoimmune hepatitis (AI) comprised 16% of cases, the remainder (83%) being viral in origin (CVH). Of the cases of viral hepatitis, the most common is Hepatitis C (HCV) (56%), followed by Hepatitis B (HBV) (25%) and HBV/HCV co-infection (3%).
Chronic Viral Hepatitis (Primary and Secondary) in Adult Patients by Era
7%
81%
12%
27%54%
19%
37%53%
10%
1986-1993 2001-20081994-2001
HBV (n=106)
HCV (n=199)
Other (n=464)
Chronic Viral Hepatitis (Primary and Secondary) in Adult Patients by Era
The number of patients requiring transplantation due to HBV and HCV has steadily increased over the three time periods.
RECIPIENT DEMOGRAPHICS
Data to 31/12/2008 © copyright ANLTU 20
0%
20%
40%
60%
80%
100%
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Other (n=441) HBV (n=128) HCV (n=200)
% Adults with HBV or HCV at Transplantation
HCV infection comprises 25% of adults transplanted, and is expected to continue to rise in the future.
Fulminant Hepatic Failure Treated by Liver Transplantation Fulminant Hepatic Failure Treated by Liver Transplantation
Outcome Aetiology No. of Patient
s No. of Tx Alive Dead
Idiopathic 43 46 30 (70%) 13
Drug induced 15 16 10 (67%) 5
Wilson’s Disease 11 13 10 (91%) 1
Viral Hepatitis
Hep B 22 23 12 (55%) 10
Hep C 1 1 1 (100%) 0
Hep A 3 3 0 3
Hep E 1 1 0 1
Auto Immune Hepatitis 2 2 1 (50%) 1
Budd-chiari 1 1 0 (0%) 1
Other 1 1 1 (100%) 0
Totals 100 107 65 35
65% Pts 35% Pts
RECIPIENT DEMOGRAPHICS
Data to 31/12/2008 © copyright ANLTU 21
Indication For Secondary Transplantation
7
11
4
6
2
5
2
5
4
59
2
4
1
2
6
3
0
2
4
6
8
10
12
14
16
0-7d 8-30d 1-6m 6m-1y 1-5y >5y
Vascular Rejection PNF Viral recurrence Biliary Strictures Other
n = 79
Indication for Secondary Transplantation
Primary non function (PNF) is the sole indication for re-transplantation in the first 7 days. Rejection and vascular indications are prominent indications for re-transplantation in all other time periods.
Data to 31/12/2008 © copyright ANLTU 22
PERIOPERATIVE DATA
PERIOPERATIVE DATA
Data to 31/12/2008 © copyright ANLTU 23
Mean/Median Hospital Stay
9
5 5 6 53 4 3 3
5 52 3 3 3 4 4 4
64
86
4
36
32
44
49
42
32
38
34 34
40
26
32
42
25 25 2624
2118
2320
15
19
0
10
20
30
40
50
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
ICU (Mean)Ward (Mean)ICU (Median)Ward (Median)
Mean/Median Hospital Stay (days)Adults Only
Red Cell Usage
133
73
133
86
42
3238
14
35
24
38
14 16 13 16
6 4 4 5 84
60
20
40
60
80
100
120
140
86-98 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Red Cell UsageMedian
(Units of Packed Cells)
Red Cell Usage
Graft Ischaemic Time, Operation Duration and Red Cell Utilisation
Graft Ischaemic Time, Operation Duration and Red Cell Utilisation
1986 - 1993 1994 - 2000 2000 – 2008
Mean graft ischaemic time 9Hrs 4 Mins 9Hrs 35 Mins 9Hrs 4 Mins
Mean operation duration 7Hrs 49 Mins 8Hrs 26 Mins 6Hrs 40 Mins
1 - 133 2 - 133 0 – 86
No. packed cells utilised Mean 20 / Median 15 Mean 21 / Median 17 Mean 7 / Median 4
Data to 31/12/2008 © copyright ANLTU 24
OUTCOME DATA
OUTCOME
Data to 31/12/2008 © copyright ANLTU 25
Patient Survival
1y 5y 10y 15y 20y
No at Risk 755 497 262 124 16
Actuarial Survival % 85 77 67 59 51
6m 12m 18m 24m No at Risk 72 48 27 2
Actuarial Survival % 97 97 94 94
1y 5y 10y 15y 20yNo at Risk 611 399 209 89 10
Adult Actuarial Survival % 85 76 64 56 48
No at Risk 144 98 53 35 6 Child
Actuarial Survival % 86 83 78 76 68
6m 12m 18m 24m
No at Risk 58 37 19 1 Adult
Actuarial Survival % 98 98 93 93
No at Risk 14 11 8 1 Child
Actuarial Survival % 95 95 95 95
Overall Patient Survival1986 - 2008
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20 22Years Post Tx
% S
urviv
ing
n = 947
Patient Survival 1986-2008Adults vs Children
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20 22Years Post Tx
% S
urvi
ving
Children (n=178)Adults (n=769)
p=0.001
Patient SurvivalAdults vs Children 2007-2008
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20 22 24Months Post Tx
% S
urvi
ving
Children (n=22)Adults (n=83)
p=ns
Patient Survival 2007-2008
0
20
40
60
80
100
0 6 12 18 24Months Post Tx
% S
urvi
ving
n = 105
94949797Actuarial Survival %2274898No at Risk
24m18m12m6m
OUTCOME
Data to 31/12/2008 © copyright ANLTU 26
Children vs Weight
Children - Weight vs Outcome(Primary Grafts)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Years Post Tx
% S
urvi
ving >10 (n=94)
<=10 (n=84)p<0.5
6880838992Actuarial Survival %
424366384No at Risk>10 kg
7373737679Actuarial Survival %
211173560No at Risk<=10 kg
20 Yr15 Yr10 Yr5Yr1 Yr
Paediatric Transplants Paediatric Transplants
Survival
Patients
(alive with these grafts)
Grafts (still function)
< 10 Kg 22/39 56% 19/42 46%
> 10 Kg 28/36 78% 27/41 68% Reduced liver grafts*
Subtotal 49/74 66% 46/83 57%
< 10 Kg 22/25 88% 22/25 90%
> 10Kg 22/25 88% 20/28 76% Split liver grafts
Subtotal 44/50 88% 42/53 82%
< 10 Kg 14/15 93% 13/15 87%
> 10 Kg 32/38 84% 30/42 73% Whole liver grafts*
Subtotal 46/53 87% 43/57 77%
< 10 Kg 6/6 100% 6/6 100%
> 10 Kg 4/5 80% 4/5 80% Living Donor Graft
Subtotal 10/11 91% 10/11 91%
TOTAL 144/179 80% 141/204 79% Note: - 2 children who had failed primary whole grafts, went on to have a reduced graft - 3 children survive with a second transplant as an adult - 2 children survive with re-transplant in other unit
Children - Type of Transplant vs Outcome(Primary Grafts)
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20
Years Post Tx
% S
urvi
ving Whole (n=50)
Split (n=46)Reduced (n=81)
7373747478Actuarial Survival %
716243036No at RiskSplit
8686919191Actuarial Survival %
4648515360No at RiskReduced
9494949494Actuarial Survival %
4445464647No at RiskWhole
5 Yr4 Yr3 Yr2 Yr1 Yr
OUTCOME
Data to 31/12/2008 © copyright ANLTU 27
Primary Disease and Outcome Primary Disease and Outcome
Disease No of patients
1 year survival
%
5 year survival
%
10 year survival
%
15 year survival
%
20 year survival
% ALCOHOLIC CIRRHOSIS 74 89 82 61 55
BILIARY ATRESIA 103 84 80 80 80 80
AUTOIMMUNE 41 90 83 70 62 62
CHRONIC VIRAL HEPATITIS 223 86 74 64 53
HEPATITIS B POSITIVE 66 78 67 65 54
HEPATITIS B & C POSITIVE 9 100 100 100 100 100
HEPATITIS C POSITIVE 148 86 75 57 45 34
CRYPTOGENIC CIRRHOSIS 25 71 67 58 39
FULMINANT HEPATIC FAILURE 100 74 72 65 59 41
MALIGNANCY 76 89 70 52 52
METABOLIC 110 88 82 76 66
OTHER 49 79 79 62 55
PRIMARY SCLEROSING CHOLANGITIS 87 87 77 67 61 32
PRIMARY BILIARY CIRRHOSIS 58 90 82 65 59
TOTAL 947 85 77 67 59 51
Primary Disease vs OutcomeAdults and Children
10
20
30
40
50
60
70
80
90
100
0 2 4 6 8 10 12 14 16 18 20 22Years Post Tx
% S
urvi
ving
HBV,HCV (n=9)BA (n=6)Autoimmune (n=42)Metabolic (n=110)HBV (n=66)CC (n=25)Other (n=49)PSC (n=87)PBC (n=58)Malignancy (n=76)HCV (n=148)Alcohol (n=74)
P 0 088
OUTCOME
Data to 31/12/2008 © copyright ANLTU 28
Primary Disease vs OutcomeAdults
10
20
30
40
50
60
70
80
90
100
0 2 4 6 8 10 12 14 16 18 20 22
Years Post Tx
% S
urvi
ving
HBV,HCV (n=9)BA (n=6)Autoimmune (n=42)PBC (n=58)HBV (n=66)Other (n=40)PSC (n=87)Malignancy (n=71)Alcohol (n=74)Metabolic (n=60)HCV (n=148)CC (n=24)
P 0 088
Primary Disease vs OutcomeChildren
20
30
40
50
60
70
80
90
100
0 2 4 6 8 10 12 14 16 18 20 22
Years Post Tx
% S
urvi
ving
CC (n=1)Other (n=9)BA (n=97)Metabolic (n=50)Malignancy (n=5)
P 0 088
OUTCOME
Data to 31/12/2008 © copyright ANLTU 29
Fulminant Disease and Outcome
Fulminant Disease vs Outcome(Adults and Children)
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20Years Post Tx
% S
urvi
ving
n=100
4159657274Actuarial Survival %118334870No at Risk20 Yr15 Yr10 Yr5 Yr1 Yr
Fulminant Disease vs Outcome(Adults vs Children)
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20Years Post Tx
% Surviving
Children (n=16)Adults (n=84)
Actuarial Survival %
No at Risk
Actuarial Survival %
No at Risk
94949494CHILDREN
561015
53596871
13273855ADULTS
15 Yr10 Yr5 Yr1 Yr
p < 0.05
OUTCOME
Data to 31/12/2008 © copyright ANLTU 30
Status at Transplant vs Pt Outcome
Status vs Outcome(Adults and Children - Primary Grafts)
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20Years Post Tx
% SurvivingAt Home (n=394, 42%)Hospital Bound (n=149, 16%)Occasional Inpatient (n=317, 33%)ICU (n=87, 9%)
4550606769 Actuarial Survival %
113253657 No at RiskICU
4558657785 Actuarial Survival %
653104179254 No at RiskOccasionalpatient
4654606880 Actuarial Survival %
3224173110 No at RiskHospital bound
6565728290 Actuarial Survival %
63692209334 No at RiskAt home
20 Yr15 Yr10 Yr5 Yr1 Yr
Viral Disease vs Outcome
Chronic Viral, Autoimmune Disease vs Outcome(Primary Grafts)
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20Years Post Tx
% Surviving
B,C (n=9)AI (n=42)HBV (n=66)HCV (n=148)
3445577589 Actuarial Survival %
152365118 No at RiskHCV
5454656778 Actuarial Survival %
1 9244050 No at RiskHBV
6262708390 Actuarial Survival %
3 13192937 No at RiskAI
100 100 100 100 100 Actuarial Survival %
12579 No at RiskB, C
20 Yr15 Yr10 Yr5 Yr1 Yr
HBV/HCV co-infection demonstrated superior patient survival at 100%, as compared to HCV infection alone.
OUTCOME
Data to 31/12/2008 © copyright ANLTU 31
Chronic HBV Outcomes
Chronic HBV Before and After Prophylaxis Protocol*(Primary and Secondary Indication)
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20
Years Post Tx
% S
urvi
ving
Post 23/2/1996 (n=71)Pre 23/2/1996 (n=33)
p<0.1
71777790Actuarial Survival %
2133759No at RiskPost 23/02/1996
5151586173Actuarial Survival %
111192024No at RiskPre 23/02/1996
20y15y10y5y1y
*oral nucleos(t)ide therapy + low dose monthly IMI HBIG
Chronic HBV(Primary and Secondary) vs Era
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20
Years Post Tx
% Surviving
2002-2008 (n=31)1994-2001 (n=51)1986-1993 (n=22)
8593 Actuarial Survival %
824 No at Risk02-08
57717186 Actuarial Survival %
2 203644 No at Risk94-01
5050555968 Actuarial Survival %
111121315 No at Risk86-93
20 Yr15 Yr10 Yr5 Yr1 Yr
Chronic HCV Outcomes
Chronic HCV(Primary and Secondary) vs Era
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20Years Post Tx
% Surviving
1986-1993 (n=14)2002-2008 (n=113)1994-2001 (n=72)
p=ns
8193Actuarial Survival %
2790No at Risk02-08
46557285Actuarial Survival %
4265261No at Risk94-01
4957648686Actuarial Survival %
2891212No at Risk86-93
20 Yr15 Yr10 Yr5 Yr1 Yr
OUTCOME
Data to 31/12/2008 © copyright ANLTU 32
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20Years Post Tx
% S
urvi
ving
Secondary (n=51)Primary (n=148)
p=ns
Chronic HCV Primary vs Secondary Indication
5757658592Actuarial Survival %
13122645No at RiskSecondary
3445577589Actuarial Survival %
152365118No at RiskPrimary
20y15y10y5y1y
Chronic HCV (Primary & Secondary)vs Associated HCC
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20Years Post Tx
% S
urvi
ving
HCV no HCC (n=125)HCV with HCC (n=74)
p=ns
54547387Actuarial Survival %
192658No at RiskWith HCC
4350628091Actuarial Survival %
282665105No at RiskNo HCC
20y15y10y5y1y
OUTCOME
Data to 31/12/2008 © copyright ANLTU 33
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20 22Years Post Tx
% S
urvi
ving
>65 (n=12)11-30 (n=55)61-65 (n=13)31-50 (n=83)51-60 (n=37)
HCV vs Donor Age vs Primary Graft OutcomeAdults (n=200)
Non HCV vs Donor Age vs Primary Graft OutcomeAdults (n=569)
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20 22
Years Post Tx
% Surviving
61-65(n=17)
0-10 (n=7)
11-30 (n=196)
51-60(n=102)
>65 (n=44)
31-50 (n=203)
1y 5y 10y 15y 20y
11 - 30 No at Risk 52 37 18 3 1
Actuarial Survival % 98 94 79 79 79
31 - 50 No at Risk 66 38 14 4 1
Actuarial Survival % 86 74 58 39 39
51 - 60 No at Risk 27 8 2 2
Actuarial Survival % 83 53 21 21
61 - 65 No at Risk 9 5 2
Actuarial Survival % 83 83 65
> 65 No at Risk 10 4 1 Actuarial Survival % 100 88 88
1y 5y 10y 15y 20y
No at Risk 4 4 4 2 0 - 10 Actuarial Survival % 57 57 57 57
No at Risk 152 120 76 37 5 11 - 30 Actuarial Survival % 81 75 65 57 52
No at Risk 170 114 67 27 3 31 - 50 Actuarial Survival % 87 76 69 58 42
No at Risk 76 48 21 12 1 51 - 60 Actuarial Survival % 82 71 57 50 50
No at Risk 13 8 3 1 61 - 65 Actuarial Survival % 82 82 71 71
No at Risk 32 13 2 1 > 65 Actuarial Survival % 83 74 49 49
OUTCOME
Data to 31/12/2008 © copyright ANLTU 34
Donor Age vs Primary Graft Outcome
Donor Age vs Primary Graft Outcome
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20 22Years Post Tx
% Surviving
0-10 (n=62)61-65 (n=30)11-30 (n=313)>65 (n=57)31-50 (n=336)51-60 (n=149)
1y 5y 10y 15y 20y 0 - 10 No at Risk 51 47 25 15 2 Actuarial Survival % 84 84 81 81 81 11 - 30 No at Risk 253 188 112 56 8 Actuarial Survival % 85 79 70 64 56 31 - 50 No at Risk 275 171 92 35 6 Actuarial Survival % 86 76 67 54 43 51 - 60 No at Risk 111 60 25 15 1 Actuarial Survival % 82 69 51 46 42 61 - 65 No at Risk 22 13 5 1 1 Actuarial Survival % 82 82 69 69 69
> 65 No at Risk 43 18 3 2
Actuarial Survival % 87 77 58 58
OUTCOME
Data to 31/12/2008 © copyright ANLTU 35
Steatosis vs Graft Outcome (Adults)
Steatosis (Micro) vs Graft Outcome (Adults)2001 – 2008
40
60
80
100
0 2 4 6 8Years Post Tx
% S
urvi
ving
S0 (n=97)S1 Mi (n=70)S2 Mi (n=22)S3 Mi (n=24)
7377Actuarial Survival %
623No at RiskS3 Mi9696Actuarial Survival %
717No at RiskS2 Mi
5y1y
8390Actuarial Survival %
1361No at RiskSi Mi
8391Actuarial Survival %
2265No at RiskS0
5y1y
Steatosis (Macro) vs Graft Outcome (Adults)2001 – 2008
0
20
40
60
80
100
0 2 4 6 8Years Post Tx
% S
urvi
ving
S2 Ma (n=10)S0 (n=97)S1 Ma (n=72)S3 Ma (n=6)
83100Actuarial Survival %
1No at RiskS3 Ma50Actuarial Survival %
410No at RiskS2 Ma
5y1y
7285Actuarial Survival %
1749No at RiskSi Ma
8391Actuarial Survival %
2265No at RiskS0
5y1y
OUTCOME
Data to 31/12/2008 © copyright ANLTU 36
Graft Survival by Era Graft Survival by Era
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20 22
Years Post Tx
% Surviving
2002-20081994-20011986-1993
596878Actuarial Survival %
120240274No at Risk1994-2001
8189Actuarial Survival %2002-2008
94314No at Risk
3946526270Actuarial Survival %
14120135162184No at Risk1986-1993
20y15y10y5y1y
Graft Survival by Era
Adults
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20 22
Years Post Tx
% Surviving
2002-2008 (n=328)1994-2001 (n=294)1986-1993 (n=200)
586678Actuarial Survival %
105200229No at Risk1994-2001
8089Actuarial Survival %2002-2008
76248No at Risk
3743506272Actuarial Survival %
986100124143No at Risk1986-1993
20y15y10y5y1y
Graft Survival by Era
Children
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20 22
Years Post Tx
% Surviving
2002-2008 (n=85)1994-2001 (n=57)1986-1993 (n=62)
647079Actuarial Survival %
154045No at Risk1994-2001
8491Actuarial Survival %2002-2008
1866No at Risk
4555566166Actuarial Survival %
534353841No at Risk1986-1993
20y15y10y5y1y
OUTCOME
Data to 31/12/2008 © copyright ANLTU 37
Split vs Reduced vs Whole Graft Outcome
Split vs Whole Grafts (Adults)2002-2008
20
40
60
80
100
0 2 4 6Years Post Tx
% S
urvi
ving Split (n=56)
Whole (n=270)p=0.426
8081818490Actuarial Survival %65107131166206No at RiskWhole8787878789Actuarial Survival %1121273342No at RiskSplit
5 Yr4 Yr3 Yr2 Yr1 Yr
20
40
60
80
100
0 1 2 3 4 5 6Years Post Tx
% S
urvi
ving Whole (n=8)
Part Organ (n=20)Split (n=45)
Split vs Reduced vs Whole Graft Outcome(Children) - 2002-2008
Primary Grafts
9595959595Actuarial Survival %
514212735No at RiskSplit
8585858591Actuarial Survival %
5791115No at RiskPart Organ
100100100100100Actuarial Survival %
56778No at RiskWhole
5 Yr4 Yr3 Yr2 Yr1 Yr
Split vs Part Organ vs Whole Graft Outcome (Children) – 2002-2008
Patient Outcome
20
40
60
80
100
0 1 3 4 5 6
Years Post Tx
% S
urvi
ving
Whole (n=8)
Part Organ (n=20)
Split (n=45)
9595959595Actuarial Survival %
716243036No at RiskSplit
8888939393Actuarial Survival %
5791115No at RiskPart Organ
100100100100100Actuarial Survival %
56778No at RiskWhole
5 Yr4 Yr3 Yr2 Yr1 Yr
OUTCOME
Data to 31/12/2008 © copyright ANLTU 38
Graft Outcome
Graft Number vs Outcome
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20 22Years Post Tx
% Surviving
1st Grafts (n=947)2nd Grafts (n=69)3rd Grafts (n=10)
58585858 Actuarial Survival %
1125 No at Risk3rd
1734385565 Actuarial Survival %
16112943 No at Risk2nd
4755627382 Actuarial Survival %
14114243465724 No at Risk1st
20y15y10y5y1y
Graft Survival 2007-2008
0
20
40
60
80
100
0 6 12 18 24
Months Post Tx
% S
urvi
ving
3rd Grafts (n = 3)1st Grafts (n=105)2nd Grafts (n=5)
3978Actuarial Survival %
122No at Risk3rd 100100100Actuarial Survival %
12No at Risk
2nd
94949797Actuarial Survival %
2274872No at Risk1st
24 m18 m12 m6 m
OUTCOME
Data to 31/12/2008 © copyright ANLTU 39
Survival of Special Groups
Survival of Special Groups
Patients Grafts
Adults Children Adults Children
Multiple grafts 27/51 53% 13/24 54% 28/58 48% 12/24 46%
Reduction hepatectomy 2/6 33% 49/74 66% 2/6 33% 46/83 55%
Split liver 51/57 90% 44/50 88% 49/57 86% 42/53 79%
Living donor tx 1/1 100% 10/11 91% 1/1 100% 10/11 91%
Fulminant hepatic failure 51/84 61% 14/16 88% 51/90 57% 14/17 82%
ABO incompatible 12/15 80% 4/7 57% 12/15 80% 4/7 57%
A2 – O (1999-2007) 5/6 83% 1/1 100% 5/6 83% 1/1 100%
Hepatic malignancy
Primary indication 49/71 69% 2/5 40% 49/74 66% 2/5 40%
Secondary indication 52/81 64% 52/82 63%
OUTCOME
Data to 31/12/2008 © copyright ANLTU 40
Cause of Death Cause of Death
Graft Failure 81 (28%)
Rejection
Acute 10
Chronic 23
Recurrent disease
Hepatitis B 11
Hepatitis C 20
NASH 1
PNF 3
Biliary Complications 4
Vascular 9
Sepsis 57 (20%)
Malignancy 45 (16%)
Recurrent disease 18
De Novo 25
Transferred from donor 2
Cerebral 24 (8%)
Cardiovascular 17 (6%)
Other 15 (5%)
Respiratory 15 (5%)
Operative 10 (4%)
Multi-organ Failure 5 (2%)
Vascular 5 (2%)
Gastrointestinal 6 (2%)
GVHD 4 (1%)
Renal Failure 2
TOTAL 286 (30% of all pts)
OUTCOME
Data to 31/12/2008 © copyright ANLTU 41
Cause of Death(n=286)
Respiratory5%
GI2%
Rejection12%
Recurrent Disease11%
Biliary Complication1%
PNF1%
Operative3%
Sepsis21%
Malignancy16%
Cerebral8%
Other11%
Cardiovascular6%
Graft Failure29%
Vascular3%
286 patients, or 30% of all patients transplanted, have died. 57 (20%) have died due to sepsis and 81 (28%) from graft failure. Of the 81 cases of death due to graft failure, 33 (12%) patients lost grafts due to rejection, 32(11%) from recurrent disease and 3 (1%) from primary non function (PNF).
Cause of Death(n=286)
Respiratory5%
GI2%
Cardiovascular6%
Other11%
Cerebral7%
Malignancy17%
Sepsis20%
Operative4%
Graft failure28%
Adults (n=251) Children (n=35)
Respiratory9%
Cardiovascular3%
Other11%
Cerebral20%
Malignancy9%
Sepsis23%
Graft failure25%
The majority of adult deaths were due to Graft Failure (72 or 28%), Sepsis (49or 20%) and Malignancy (42 or 17%). The majority of child deaths were due to Sepsis (8 or 23%) or Graft Failure (9 or 25%) and Cerebrovascular accident (7 or 20%).
OUTCOME
Data to 31/12/2008 © copyright ANLTU 42
Cause of Death by Time – Adults(n=251)
10
21
3
14
10
24
7
10
4
15
4
19
7
52
33
21
3
15
12
44
4
13
67
44
8
52
33
38
11
2
10
9
35
26
22
12
47
12
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<1wk 1 mth 6 mths 1 yr >1 yr >5 yr
Sepsis
Respiratory
Operative
Miscellaneous
Malignancy
Graft failure
Gastrointestinal
Cerebral
Cardiovascular
n = 76 (30%)61 (24%)24 (10%)37 (14%)27(11%)29 (12%)
2
4
2
4
2
1
1
2
2
3
1
1
2
1
1
1
3
2
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<1 wk 1 mth 6 mths 1 yr >1 yr >5 yr
Sepsis
Respiratory
Operative
Miscellaneous
Malignancy
Graft failure
Gastrointestinal
Cerebral
Cardiovascular
n = 6 (17%)5 (14%)1 (3%)8 (23%)7 (20%)8 (23%)
Cause of Death by Time – Children(n = 35)
OUTCOME
Data to 31/12/2008 © copyright ANLTU 43
Cause of Graft Failure Cause of Graft Failure
Rejection 59 (16%) Acute 15 Subacute 1 Chronic 35 ABO incompatibility 6 Vascular complications Hepatic artery 45 (12%) Thrombosis 30
Secondary haemorrhage 1
Rupture 1 Dissection in donor 1
Portal vein thrombosis Portal vein erosion Hepatic vein stenosis
3 1 1
Graft infarction 2 Vena Cava obstruction 1
Splenic aneurysm rupture 3
Graft compression 1 Recurrent disease 59 (16%) Hep B 13 Hep C 27 Malignancy 17 PSC 1 NASH 1 Primary non function 12 (3%) Arterial thrombosis 1 Vena 1 Graft infarction 5 Profound hypotension 1 Preservation injury 1 Severe steatosis 3 Patient deaths 174(47%) Sepsis 54 Cerebral 22 Other 17 Malignancy 28 Respiratory failure 15 Cardiovascular 17 Intraoperative 9 GI haemorrhage 5
GVHD Pancreatitis
4 3
Biliary complications 16(4%) Biliary strictures 14 Other 2 Other 5 (1%) TOTAL 368 (36%) 0f all grafts
OUTCOME
Data to 31/12/2008 © copyright ANLTU 44
Cause of Graft Failure
Other, 1%
Malignancy, 8%
Other, 5%
Cardiac, 5%
Intraop, 2%
Respiratory, 4%
Cerebral, 6%
GI, 1%
Biliary, 4%
Pancreatitis, 1%
Rejection, 15%
PNF, 3%
Vascular, 12%
Recurrent Disease, 17%
GVHD, 1%
Sepsis, 15%
Pt Death, 47%
368 of 1026 grafts (36%) have failed. 174 grafts (46%) were lost due to patient deaths, 57 (15%) due to rejection and 59 (17%) due to disease recurrence. Sepsis was the most significant cause of patient death (54 patients), followed by malignancy (28 patients) and cerebral catastrophe (22 patients). .
Vascular25%
PNF6%
Pt Death32%
Rejection24%
Biliary8%
Other5%
Cause of Failure
Vascular10%
Pt Death49%
Other1% PNF
3%
Biliary4%
Rejection14%Recurrent
Disease19%
Adultsn = 305
Childrenn = 63
Patient death was the most significant cause of graft failure, followed by rejection.
OUTCOME
Data to 31/12/2008 © copyright ANLTU 45
21
71
53
55
25
20
2
56
10
10
22
3
17
41
28
10
4
38
41
10
6
83
58
18
13
3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<1 wk 1 mth 6 mths 1 yr >1 yr >5 yr
Vascular
Rejection
Recurrent disease
Pt Death
PNF
Other
Biliarycomplication
Cause of Graft Failure by Time – Adults(n = 305)
n = 80 (26%)68 (22%)29 (10%)50 (16%)40 (13%)38(13%)
4
4
4
5
2
4
1
5
3
1
1
1
3
2
1
2
5
4
4
1
2
2
2
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<1 wk 1 mth 6 mths 1 yr >1 yr >5 yr
Vascular
Rejection
Pt Death
PNF
Other
Biliarycomplication
Cause of Graft Failure by Time – Children(n = 63)
N = 11 (18%)12(19%)7 (11%)10 (16%)11 (18%)12 (19%)
OUTCOME
Data to 31/12/2008 © copyright ANLTU 46
Malignancy at Transplantation
1 2 1 1 2 13
7
119
11
7 7 8
14 1411
17
12
13
1
1
1
1
1
1
1
1
1
1
1 2 11
0
2
4
6
8
10
12
14
16
18
20
198719881990199119921993199419951996199719981999200020012002200320042005200620072008
Misc (n=6)Hepatoblastoma (n=3)Cholangiocarcinoma (n=10)HCC (n=139)
Malignancy at Transplantationn = 158 (17% of all pts)
3 3 3
5
87 7
5 5
8
14
11 11
14
10
0
3
0
23
2
4
2 2
0 0
3
0
32
0
2
4
6
8
10
12
14
16
Pre1990
90-95 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Known HCC (n=114)Found in explant (n=25)
HCC at Transplantation
n = 139
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15Years Post Tx
% Surviving
2002-2008 (n=83)1994-2001 (n=51)1986-1993 (n=5)
p<05
HCC vs Era(Primary and Secondary Indication)
20 40 60 Actuarial Survival %
1 2 3 No at Risk86-93
577186 Actuarial Survival %
153644 No at Risk94-01
7788Actuarial Survival %
1162No at Risk02-08
10 Yr5 Yr1 Yr
Benign Disease vs Malignancy
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20 22
Years Post Tx
% S
urvi
ving
Benign disease (n=790)Malignant disease (n=158)
p=ns
3953697387Actuarial Survival %
4215680124No at Risk
Malignant Disease
546269788085Actuarial Survival %
16120241441535631No at Risk
20y15y10y5y3y1yBenign Disease
Data to 31/12/2008 © copyright ANLTU 47
Cancer after transplantation
CANCER AFTER TRANSPLANTATION
Data to 31/12/2008 © copyright ANLTU 48
De novo Non Skin Cancer Post Transplant
De Novo Non Skin Cancer
NB: m = median
7(42%)232.3 - 217 (m 73)
1.5 - 78 (m 51)243155Total
005.667101Multiple Myeloma
0(100%)214 – 93 (m=53)
66 – 75 (m 70)112CNS
0(100%)234 - 170 (m 102)
29-46 (m 37)022Respiratory
0(33%)147 – 145 (m 99)
36 – 70 (m 63)213Endocrine
0(50%)250 – 205 (m 86)
30 – 45 (m 43)404Breast
102.3 – 165 (m 16)
39 – 66 (m 46)257Genitourinary
004832011Kaposi’s
3(29%)44 – 183 (m 67)
1.5 – 70 (m 41)6814Lymphoma*
3(57%)1210 -217 (m 79)
13 – 78 (m 58)81321Alimentary*
Died Other
Died of This Cancer
Time to diagnosis
(mths)
Age of pts (yrs)FemaleMaleNo
Breast7%
CNS4%
Endocrine5%
Respiratory4%
Upper GI5%
Pancreas4%
Multiple myeloma2%
Kaposi's2%
Lower GI27%
Mouth2%
Genitourinary13%
Lymphoma25%
Alimentary41%
De Novo Non Skin Cancern=55 (6% pts transplanted)
CANCER AFTER TRANSPLANTATION
Data to 31/12/2008 © copyright ANLTU 49
Pre Transplant Liver Disease andDe Novo Non Skin Cancer
2
4
23
6
3 1
5
3
1
1 11
1
1
2
1
0
2
4
6
8
10
12
14
PSC+AI HBV HCV PBC Alcohol
OtherEndocrineCNSKaposi'sGenitourinaryAlimentaryLymphoma
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Years Post Tx
Patients at Risk (947)
Any CaSkinDe Novo Non skinAge-Matched Gen. Pop
Cumulative Risk of Diagnosis of Cancer Following Liver Tx. 1986 - 2008