DEFINITION AND CLASSIFICATION OF NEGATIVE OUTCOMES IN SOLID-ORGAN TRANSPLANTATION - APPLICATION IN LIVER-TRANSPLANTATION

Objective This study defined negative outcomes of solid organ transpla ntation, proposed a new classification of complications by severity, a nd applied the classification to evaluate the results of orthotopic li ver transplantation (OLT). Summary and Background Data The lack of uni form reporting of negative outcomes has made reports of transplantatio n procedures difficult to interpret and compare. In fact, only mortali ty is well reported; morbidity rates and severity of complications hav e been poorly described. Methods Based on previous definition and clas sification of complications for general surgery, a new classification for transplantation in four grades is proposed. Results including risk factors of the first 215 OLTs performed at the University of Toronto have been evaluated using the classification. Results All but two pati ents (99%) had at least one complication of any kind, 92% of patients surviving more than 3 months had grade 1 (minor) complications, 74% ha d grade 2 (life-threatening) complications, and 30% had grade 3 (resid ual disability or cancer) complications. Twenty-nine per cent of patie nts had grade 4 complications (retransplantation or death). The most c ommon grade 1 complications were steroid responsive rejection (69% of patients) and infection that did not require antibiotics or invasive p rocedures (23%). Grade 2 complications primarily were infection requir ing antibiotics or invasive procedures (64%), postoperative bleeding r equiring >3 units of packed red cells (35%), primary dysfunction (26%) , and biliary disease treated with antibiotics or requiring invasive p rocedures (18%). The most frequent grade 3 complication was renal fail ure, which is defined as a permanent rise in serum creatinine levels g reater than or equal to twice the pretransplantation values(11%). Grad e 4 complications (retransplantation or death) mainly were infection ( 14%) and primary dysfunction (11%). Comparison between the first and l ast 50 OLTs of the series indicates a significant decrease in the mean number of grade 1 and 2 complications. This was partially a result of better medical status of patients at the time of transplantation. Usi ng univariate and multivariate analyses of risk factors, the best pred ictor of grade 1 complications was donor obesity; for grade 2 complica tions, the best predictor was a donor liver rewarming time of >90 minu tes, and for grade 3 and 4 complications, the best predictor was the A PACHE II scoring system and donor cardiac arrest. Conclusions Standard ized definitions and classification of complications of transplantatio n will allow us to better evaluate and compare results of transplantat ion among centers and over time, and better compare effectiveness of n ew therapies. Orthotopic liver transplantation still is a procedure wi th high morbidity that requires careful analysis of risk factors to op timize selection of patients and organ sharing.