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Revascularization Time in Liver Transplantation

Independent Prediction of Inferior Short- and Long-term Outcomes by Prolonged Graft Implantation

Buchholz, Bettina M., MD1; Gerlach, Undine A., MD, PhD1,2; Chandrabalan, Vishnu V., MD1; Hodson, James, BS3; Gunson, Bridget K.1; Mergental, Hynek, MD, PhD1; Muiesan, Paolo, MD1; Isaac, John R., MD1; Roberts, Keith J., MD, PhD1; Mirza, Darius F., MD1; Perera, M. Thamara P. R., MD1

doi: 10.1097/TP.0000000000002263
Original Clinical Science—Liver

Background Strategies for successful transplantation are much needed in the era of organ shortage, and there has been a resurgence of interest on the impact of revascularization time (RT) on outcomes in liver transplantation (LT).

Methods All primary LT performed in Birmingham between 2009 and 2014 (n = 678) with portal reperfusion first were stratified according to RT (<44 minutes vs ≥44 minutes) and graft quality (standard liver graft [SLG], Donor Risk Index < 2.3 vs marginal liver graft [MLG], Donor Risk Index ≥ 2.3).

Results Revascularization time of 44 minutes or longer resulted in significantly greater incidence of early allograft dysfunction (EAD) (29% vs 47%, P < 0.001), posttransplant acute kidney injury (AKI) (39% vs 60%, P < 0.001), and new-onset AKI (37% vs 56%, P < 0.001), along with poor long-term outcome (3-year graft survival 92% vs 83%, P = 0.001; 3-year patient survival 87% vs 79%, P = 0.004). On multivariable analysis, RT ≥ 44 was a significant independent predictor of EAD, renal dysfunction, and overall graft survival, but not patient survival. The cumulative effect of prolonged revascularization in marginal grafts (MLGRT ≥ 44) resulted in the worst transplant outcome compared with all other groups, which could be mitigated by rapid revascularization (SLGRT < 44, SLGRT ≥ 44, MLGRT < 44 vs MLGRT ≥ 44; EAD 24%, 39%, 39% vs 69%; AKI 32%, 46%, 51% vs 70%; 3-year graft survival 94%, 87%, 88% vs 70%, respectively; each P < 0.001). Factors associated with lack of abdominal space, larger grafts, and surgical skills were predictive of RT ≥ 44.

Conclusions Shorter graft revascularization is a protective factor in LT, particularly in the setting of graft marginality. Careful graft-recipient matching and emphasis on surgical expertise may aid in achieving better outcomes in LT.

The authors have identified an association between reperfusion time and graft and patient outcomes in liver transplantation. Whether this is causal or the consequence of unmeasured confounders will require further study.

1 Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom.

2 Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany.

3 Department of Medical Statistics, Institute of Translational Medicine (ITM), University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom.

Received 15 December 2017. Revision received 6 April 2018.

Accepted 20 April 2018.

This article was funded by the Liver Foundation Trust under Queen Elizabeth Hospital Charity to cover the publication fee. The authors declare no conflicts of interest.

B.M.B. contributed considerably to study design and acquired, analyzed and interpreted the data. B.M.B., U.A.G., and V.V.C. wrote the article. V.V.C. participated in data analysis. J.H. contributed to the statistical analysis. B.G. was substantially involved in data acquisition. H.M., P.M., J.R.I., K.J.R., and D.F.M. interpreted data and revised the article critically for intellectual content. M.T.P.R.P. provided the working hypothesis, designed the study, and critically revised the article. All authors read and approved the final article.

Correspondence: Thamara Perera, MD, Liver Unit, University Queen Elizabeth Hospital Birmingham and Birmingham Childrens' Hospital, Birmingham B15 2TH, United Kingdom. (

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