50
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.

Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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Page 1: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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.

Page 2: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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7 Patients Withdrawn From Waiting List............................................................................................ 8 Urgent Listings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

Page 3: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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

Page 4: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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

Page 5: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

Data to 31/12/2008 © copyright ANLTU 4

ASSESSMENT INFORMATION

Page 6: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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

Page 7: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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.

Page 8: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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

Page 9: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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

Page 10: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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)

Page 11: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

Data to 31/12/2008 © copyright ANLTU 10

DONOR INFORMATION

Page 12: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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

Page 13: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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

Page 14: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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%).

Page 15: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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.

Page 16: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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

Page 17: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

Data to 31/12/2008 © copyright ANLTU 16

RECIPIENT DEMOGRAPHICS

Page 18: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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%).

Page 19: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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%).

Page 20: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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.

Page 21: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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

Page 22: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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.

Page 23: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

Data to 31/12/2008 © copyright ANLTU 22

PERIOPERATIVE DATA

Page 24: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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

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OUTCOME DATA

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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

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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%

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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)

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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%).

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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)

Page 44: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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

Page 45: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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.

Page 46: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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%)

Page 47: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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

Page 48: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

Data to 31/12/2008 © copyright ANLTU 47

Cancer after transplantation

Page 49: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver 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)

Page 50: Liver Transplantation - Sydney Local Health District Transplantation at Australian National Liver Transplantation Unit Data to 31 December 2008 The Australian National Liver Transplantation

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