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Liver Transplantation for Hepatocellular Carcinoma Outside of Both Milanand UCSF Criteria: Does Etiology of Liver Disease Impact Outcomes?William C. Palmer, Justin H. Nguyen, Barry Rosser, Andrew Keaveny, Tushar Patel,Ricardo Paz-Fumagalli, Raouf Nakhleh, Denise M. Harnois

Background: Liver transplantation (LT) is the optimal treatment for selected patients withhepatocellular carcinoma (HCC). Survival of >80% at 4 years has been demonstrated forpatients with HCC meeting Milan criteria. The UCSF group reported acceptable outcomesusing a specific protocol for patients beyond Milan criteria. Proceeding with LT for HCCoutside UCSF criteria is very controversial given the concern for recurrent HCC affecting long-term outcomes. Underlying viral disease may influence post-transplant immunosuppression.However, the impact of a viral etiology on patients with HCC at higher risk of recurrenceis unknown. We sought to examine the impact of underlying etiology of liver disease onrecurrence and outcomes in patients who had explants with HCC beyond Milan and UCSFcriteria. Methods: We reviewed 87 patients after LT for HCC from 1998-2009 with explanttumor beyond Milan UCSF criteria. We compared outcomes of patients with cirrhosis dueto chronic hepatitis B or C to those from non-viral etiology, with recurrence data up to 11/2012. Results: The viral hepatitis group (n=58) had a mean LT age of 56.7 years. HepatitisC (HCV) was present in 86%, with eleven achieving SVR after transplant and one before.Mean biological MELD and mean alfa-fetoprotein (AFP) at LT were 14.4 and 537.9ng/mL,respectively. Pre-LT locoregional therapy with transarterial chemoembolization (TACE) orradiofrequency ablation (RFA) was given in 81% and 12%, respectively. At explant, meantumor count (MTC) was 4.3, mean largest tumor size (mLTS) was 4.92cm, and 46.6% hadvascular invasion. HCC recurrence occurred in 50%, with a mean patient survival time(PST) of 3.41 years. 10 of the 12 HCV patients with SVR had HCC recurrence. Patientsurvival at 1 year (1yPS) and 3 years (3yPS) was 81% and 48%, respectfully, both lowerthan the 2005-2010 Surgical Registry of Transplant Recipient (SRTR) national averages. Thenon-viral group (n=29) had a mean LT age of 61.3 years. Mean MELD and AFP were 17.3and 1190.1ng/mL, respectively. Pre-LT TACE and RFA were performed in 85% and 7%,respectively. MTC was 4.7 and mLTS was 4.95cm. 65.5% had vascular invasion. HCCrecurrence occurred in 55.2%, with a mean PST of 3.76 years. 1yPS and 3yPS was 79%and 48%, respectively, again lower than the national averages from the 2005-2010 SRTR.Conclusion: In our cohort of patients who had HCC outside of Milan and UCSF criteriathat underwent LT, the cause of liver disease did not impact recurrence of HCC or patientsurvival. Both viral and non-viral groups had similar disease burden, AFP levels, and vascularinvasion in the explant as well as cancer recurrence rates. HCV SVR did not appear toimpact HCC recurrence. Longer term survival was less favorable for patients transplantedbeyond Milan and UCSF criteria and was lower than the national average for the sametime period.

Sa1024

Prediction of Early Cardiovascular Mortality Following Liver TransplantationLisa B. VanWagner, Brittany Lapin, Josh Levitsky, Anton I. Skaro, Donald Lloyd-Jones

BACKGROUND: Historically, early mortality after liver transplantation (LT) has been dueto infection or allograft failure. It is unclear if this persists in the current era of transplantation.As the LT population ages, cardiovascular disease (CVD) prevalence is expected to riseresulting in potential excess postoperative mortality. Yet, there is currently no cardiac riskscore (CRS) specific to LT candidates available to assist in predicting CVD-related deathacross transplant centers. Thus, our aim was to 1) Describe current patterns in early (30-day) post-LT mortality and 2) Develop a LT-specific CRS for the prediction of early CVD-related mortality using a multicenter national database. METHODS: Adult recipients of afirst LT were identified from the Organ Procurement and Transplantation Network (OPTN)database between February 2002 and December 2012. Those listed as status 1 or prior toMELD inception were excluded. Recipient cause of death was manually reviewed and anindependent panel of 3 physicians was used to adjudicate case mortality. Twenty-two

S-940AASLD Abstracts

variables (significant in univariate analyses) were included in a logistic regression modelwith stepwise selection to determine a predictive model of 30-day CVD mortality, definedas a primary cause of death from arterial or pulmonary embolism, arrhythmia, heart failure,myocardial infarction, primary cardiac arrest and/or stroke. Sex and center volume wereforced into the final model. The model was internally validated using bootstrapping tech-niques. RESULTS: Of 54,697 LT recipients, 1576 (2.9%) died within 30 days. CVD-relateddeath was the leading cause of 30-day mortality, accounting for 42.1% of all deaths withan early CVD mortality rate of 1.2%. (Figure 1). Mean time to CVD death was 6.2 ± 8.2days. In multivariate analysis, 9 (6 recipient, 2 donor, 1 operative) significant predictors of30-day CVD mortality were identified: age, hospitalization status, ICU status, respiratoryfailure on a ventilator, MELD score, history of portal vein thrombosis, national organ sharing(versus local/regional), donor BMI and graft cold ischemia time (Table 1). The modelshowed moderate discrimination (c-statistic 0.66, 95% CI: 0.63-0.68, after bootstrapping).CONCLUSIONS: In the current era of liver transplantation CVD-related death is the leadingcause of early mortality. The present study provides the first prognostic model for theprediction of early CVD mortality after LT with fair model accuracy. However, inclusion ofadditional variables not currently available within the OPTN database should be consideredin order to improve model accuracy and potential clinical utility.Table 1. Multivariate predictors of 30-day cardiovascular mortality after orthotopic liver trans-plantation

Abbreviations: SD, standard deviation, CI, confidence interval; ICU, intensive care unit;BMI, body mass index

FIGURE 1: Distribution of cause of death for 1,576 adult first liver transplant recipientswho died within 30 days of liver transplantation (OPTN data 2002-2012).

Sa1025

Coeliac-Like Duodenal Pathology in Orthotopic Liver Transplant Patients onMycophenolate TherapyMaura Cotter, Ahmed Abu Shanab, Raphael Merriman, Aiden McCormick, KieranSheahan

Introduction and aims: Diarrhoea following orthotopic liver transplant (OLT) is a significantclinical problem associated with mycophenolate therapy (MPA) therapy. Although its patternof inducing injury in the lower gastrointestinal tract is well known, the injury pattern inthe duodenum is less extensively documented. We aimed to study the histological patternof duodenal injury in symptomatic OLT patients on MPA therapy and compare this withpatients diagnosed with coeliac disease and normal controls. Methods: Retrospective cohortdatabase of all duodenal biopsies in patients who had OLT were analyzed in a single centreover a 19 year period. Clinical characteristics were studied which included indication ofOLT and duodenal biopsy, immunosuppressant use, anti-tTG IgA serology and outcomes.Histological specimens were reviewed by two pathologists and compared with coeliac cases