Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access
Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc
Journal website http://www.gastrores.org

Original Article

Volume 10, Number 2, April 2017, pages 106-115


Differential Simultaneous Liver and Kidney Transplant Benefit Based on Severity of Liver Damage at the Time of Transplantation

Figures

Figure 1.
Figure 1. Correlation between serum creatinine and MELD score categories at the time of transplantation. Analysis of variance (ANOVA): mean serum creatinine in each MELD group (P = 0.0001). A linear correlation between increasing MELD score and serum creatinine (Pearson correlation coefficient 0.04, P = 0.0001).
Figure 2.
Figure 2. Prevalence of renal dysfunctions at the time of transplantation. Prevalence of patients with renal dysfunctions creatinine > 1.5 in overall study cohort and in each MELD group. A trend of increasing prevalence from low to high MELD groups (Pearson correlation R 0.46: P = 0.0001 (two-tailed)). One-way analysis of variance was used to determine the differences among the groups. All the groups are statistically significant from each other (P = 0.001).
Figure 3.
Figure 3. Distribution of patients receiving transplantation base on MELD categories. Proportion of patients receiving simultaneous liver kidney (SLK) or liver alone (LA) transplant in each MELD group and in overall study population. A trend of increasing prevalence from low to high MELD groups (Pearson correlation R 0.11: P = 0.00001 (two-tailed)). Analysis of variance was used to determine the differences among the groups. High MELD group (MELD 36 - 40) is statistically significantly different (P ≤ 0.05) compared to other groups except MELD group 31 - 35 (P = 1.0).
Figure 4.
Figure 4. Kaplan-Meier patient survival analysis at 1 year based on MELD category. In each MELD category survival was compared among three transplant recipient groups (group 1: creatinine < 1.5 receiving liver alone, group 2: creatinine > 1.5 receiving liver alone and group 3: creatinine > 1.5 receiving simultaneous liver kidney. Log rank test P values (statistically significant < 0.05) are: 16 - 20 (1 vs. 2); 21 - 25 (1 vs. 2 and 1 vs. 3); 26 - 30 (1 vs. 2); 31 - 35 (1 vs. 2 and 1 vs. 3); 36 - 40 (1 vs. 2 and 1 vs. 3).
Figure 5.
Figure 5. Analysis of deceased patients. Distribution of death within 1 year based on MELD score. (a) Proportion of post-transplantation deaths based on MELD score at transplantation in overall study cohort. (b) Proportion of post-transplantation deaths based on MELD score at transplantation in patients with and without renal dysfunctions.

Tables

Table 1. Clinical Characteristics at Transplantation
 
Clinical featuren = 30,928Clinical featuren = 30,928
SD: standard deviation; n: sample number; MELD: model for end-stage liver disease; BMI: body mass index; LTA: liver transplantation alone; SLKT: simultaneous liver and kidney transplantation; LOS: length of stay.
Age recipient: mean ± SD51.58 ± 11.17Hepatic encephalopathy
Age donor: mean ± SDNone, % (n)21.8% (6,732)
  Gender recipient: male, % (n)64.8% (20,034)Mild to moderate, % (n)59.8% (18,505)
  Gender donor: male, % (n)59.8% (18,495)Severe, % (n)17.4% (5,396)
Race recipientUnknown, % (n)1% (295)
  White, % (n)71.3% (22,066)Final MELD, mean ± SD27.366 ± 8.48
  Others, % (n)28.7% (8,862)MELD groups
Race donor16 - 20, % (n)25.2% (7,806)
  White, % (n)67.5% (20,862)21 - 25, % (n)24.4% (7,549)
  Others, % (n)32.5% (10,066)26 - 30, % (n)17.8% (5,500)
Ethnicity recipient31 - 35, % (n)13.6% (4,214)
  Non-Hispanic, % (n)86.4% (26,735)> 36, % (n)18.9% (5,859)
  Hispanic, % (n)13.6% (4,193)Child-Pugh score
BMI, mean ± SD28.30 ± 7.10Class A, % (n)1.7% (518)
Creatinine at Tx, mg/dL, mean ± SD1.93 ± 1.56Class B, % (n)25.9% (8,025)
Dialysis at Tx, % (n)16.4% (5,084)Class C, % (n)67.1% (20,759)
Albumin at Tx, mean ± SD2.84 ± 0.73Missing, % (n)5.3% (1,626)
INR at Tx, mean ± SD2.2 ± 1.7Distribution of patients based on renal functions
T. bilirubin at Tx, mg/dL, mean ± SD12.27 ± 12.5Creatinine 1.5 or less, % (n)52.5% (16,249)
AscitesCreatine > 1.5 non-dialysis LTA, % (n)28.1% (8,701)
  None, % (n)12.9% (3,986)Creatine > 1.5 non-dialysis SLKT, % (n)2.9 % (894)
  Mild to moderate, % (n)48.9% (15,129)Creatine > 1.5 dialysis LTA, % (n)10.2% (3,161)
  Severe, % (n)37.2 (11,520)Creatine > 1.5 dialysis SLKT, % (n)6.2% (1,923)
  Unknown, % (n)0.9% (293)LOS, mean ± SD18.91 ± 24.46)

 

Table 2. Distribution of Patients Based on Serum Creatinine Status at Liver Transplantation
 
MELD groupCreatinine ≤ 1.5 mg/dLCreatinine > 1.5 mg/dLLT aloneSLKDeath at 1 year
MELD: model for end-stage liver disease; LT: liver transplant; SLKT: simultaneous liver and kidney transplant.
16 - 20 (%)6,584 (21.3%)1,222 (4.0%)7,594 (24.6%)212 (0.7%)664 (2.2%)
21 - 25 (%)4,952 (16.0%)2,597 (8.4%)6,793 (22.0%)756 (2.4%)847 (2.7%)
26 - 30 (%)2,832 (9.2%)2,668 (8.6%)4,902 (15.9%)598 (1.9%)731 (2.4%)
31 - 35 (%)1,289 (4.2%)2,925 (9.5%)3,695 (12.0%)519 (1.7%)632 (2.0%)
35+ (%)592 (1.9%)5,267 (17.0%)5,127 (16.6%)732 (2.4%)1,091 (3.5%)
Total (%)16,249 (52.5%)14,679 (47.5%)28,111 (90.9%)2,817 (9.1%)3,965 (12.8%)

 

Table 3. Cox Proportional Hazard Analysis
 
VariablesUn-adjusted analysisAdjusted analysisa
P valueHR95.0% CI for HRP valueHR95.0% CI for HR
LowerUpperLowerUpper
HR: hazard ratio; CI: confidence interval; MELD: model for end-stage liver disease; BMI: body mass index; LTA: liver transplantation alone; SLKT: simultaneous liver and kidney transplantation. aAdjusted for patient’s ascites grade, albumin, bilirubin, Cr, INR, MELD, dialysis, gender, race and age, donor’s age and gender, and type of transplant.
Dialysis at transplantation: yes0.0011.4011.3211.4850.0011.2041.1191.297
Recipient race: non-White0.0611.0510.9981.1060.0011.1371.0661.213
Donor race: non-White0.0271.0581.0061.1120.0161.0641.0121.119
Ethnicity: non-Hispanic0.0370.9270.8640.9950.0010.8110.7430.885
Recipient gender: male0.1641.0360.9861.088
Donor gender: male0.1240.9630.9181.01
Recipient age > 6501.3321.2271.4450.0011.2871.1851.397
Donor age > 5501.3351.2661.4090.0011.3721.31.449
BMI < 200.431
BMI 21 - 250.310.9450.8461.056
BMI 26 - 300.2420.9370.841.045
BMI 31 - 350.0720.8980.7991.01
BMI 36 - 400.5210.9560.8341.096
BMI > 400.8811.0130.8591.193
Child-Pugh Class A0.001
Child-Pugh Class B0.2690.9010.7481.084
Child-Pugh Class C0.8111.0220.8521.226
Creatinine > 1.5 mg/dL0.0011.4171.3521.485
Creatinine ≤ 1.5 mg/dL0.001
Creatinine > 1.5 mg/dL LTA0.0011.5311.4571.6080.0011.4011.321.486
Creatinine > 1.5 mg/dL SLKT0.0011.3381.2321.4540.0041.1581.0491.277
MELD 16 - 200.001
MELD 20 - 250.0011.1621.0831.2460.0131.0951.021.175
MELD 26 - 300.0011.2941.2021.3940.0011.1641.0771.258
MELD 31 - 350.0011.3421.2391.4530.0181.111.0181.21
MELD 36 - 40 and higher0.0011.5141.411.6260.0051.1311.0381.233

 

Table 4. Death by Cr (> 1.5 vs. ≤ 1.5) and MELD Score (≥ 30 vs. < 30)
 
GroupTransplant phaseAt 1-year post-transplantationb
Number of deaths (%)Adjusted P-valueaNumber of deaths (%)Adjusted P-valuea
aAdjsuted for bilirubin, INR, dialysis, patient’s gender, BMI and type of transplant via logistic regression. bAfter excluding those who died at transplantation.
Cr ≤ 1.5 and MELD < 3085 (0.62%)< 0.0012,510 (18.34%)< 0.0001
Cr > 1.5 and MELD < 3053 (0.89%)1,524 (25.72%)
Cr ≤ 1.5 and MELD ≥ 3021 (0.92%)429 (18.94%)
Cr > 1.5 and MELD ≥ 30120 (1.37%)2,238 (25.89%)