Análisis de la morbi-mortalidad a largo plazo en trasplante hepático

Abstract

AIMS. To retrospectively review our liver transplant performance to identify factors that influenced late mortality and morbidity.<br/>METHODS. Clinical records from 279 patients with liver transplants performed in Hospital Vall d´Hebron between January 1991and December 2001 and one year of survival, were reviewed. Minimal outcome was two years (r:1yr-12yr). Medium outcome was 9 years. The data evaluated by univariate and multivariate analyses regarding clinical outcome.<br/>RESULTS. Recipients mean was 55±5years, with 11%>65 years and 65% was male. Main indication for transplantation was postnecrotic cirrhosis (60%), followed by CHC in addition to cirrhosis (28%), choleostatic cirrhosis (6%), fulminant hepatitis (2%), Budd-Chiari (1%) and metabolic cirrhosis (1%). Half of the recipients (54%) were infected by HCV. A great percentage of recipients (44%) were at Child-Pugh C stage. Concomitant diseases were: renal insufficiency in 11%, arterial hypertension in 9%, diabetes mellitus in 16% and portal thrombosis in 18%. Inmunosupression at last the first year of liver transplantation was with cyclosporina in 108 patients (39%) and tacrolimus in 169 patients (60%). Patient actuarial survival what live at least a year, was 94%, 89%, 79% and 60% at 2yr, 3yr, 5yr and 10yr respectively. Seventy-five patients died in the outcome. Causes of death were recurrence primary disease in 11%, medical complications in 7% and de novo tumors in 5%. Rate of retransplant was 10% (27 patients). From all the pre-operative variables that appeared significant in univariate analysis, the factors that showed independent predictive value of late mortality were: old recipient (OR 1,03) , renal disfunction in the first year postransplant (OR 2,1) and liver disfunction at last the first year postransplant (OR 2,2). Characteristics of the patients with the risk factor of mortality "renal disfunction", were: >60 years, renal disfunction pretransplant or in the first year postransplant and Cyclosporine in the induction. Characteristics of the patients with the risk factor of mortality "liver disfunction", were: HCV pretransplant, HCV recurrence in the first year, acute rejection in the first year and Cyclosporine in the induction. The mean long term complications in liver transplant were: arterial hypertension in 50%, renal disfunction in 49%, diabetes mellitus in 30%, hypercholesterolaemia in 19%, hypertriglyceridaemia in 18%, cardiovascular complications in 15% and de novo tumors in 14%. From all the preoperative variables that appeared significant in univariate analysis, the factors that showed independent predictive value of late morbidity were:<br/>1. Renal disfunction: old recipient, pretransplant cardiovascular complications and long stay in the hospital of the recipient.<br/>2. Arterial hypertension: pretransplant arterial hypertension and CHC pretransplant in the recipient, donor exitus by traffic accident.<br/>3. Diabetes Mellitus: pretransplant diabetes and HCV pretransplant in the recipient<br/>4. Hypercholesterolaemia: no risk factors. Tacrolimus in the first year postransplantation is protector factor.<br/>5. Hypertriglyceridaemia: cold ischaemia time>8h, donor male, intraoperative transfusion of platelets, long stay in ICU of the recipient.<br/>6. Cardiovascular complications: old recipient and pretransplant cardiovascular complications, long time since of transplantation.<br/>7. De novo tumors: old recipient.<br/>CONCLUSIONS. Old recipient, renal disfunction in the first year and liver disfunction at last the first year postTH are the most significant risk factor for late mortality. Arterial hypertension, renal disfunction and diabetes mellitus are the mean long term complications in liver transplantation, and the most significance risk factors are old recipient, HCV preTH, arterial hypertension and diabetes mellitus preTH, young donor and use Cyclosporine in the inmunosupression.