A 10-year experience of liver transplantation for hepatitis C: Analysis offactors determining outcome in over 500 patients

Objective To determine the factors affecting the outcome of orthotopic live r transplantation (OLT) for end-stage liver disease caused by hepatitis C v irus (HCV) and to identify models that predict patient and graft survival. Summary Background Data The national epidemic of HCV infection has become t he leading cause of hepatic failure that requires OLT. Rapidly increasing d emands for OLT and depleted donor organ pools mandate appropriate selection of patients and donors. Such selection should be guided by a better unders tanding of the factors that influence the outcome of OLT. Methods The authors conducted a retrospective review of 510 patients who un derwent OLT for HCV during the past decade. Seven donor, 10 recipient, and 2 operative variables that may affect outcome were dichotomized at the medi an for univariate screening. Factors that achieved a probability value less than 0.2 or that were thought to be relevant were entered into a stepdown Cox proportional hazard regression model. Results Overall patient and graft survival rates at 1, 5, and 10 years were 84%, 68%, and 60% and 73%, 56%, and 49%, respectively. Overall median time to HCV recurrence was 34 months after transplantation. Neither HCV recurre nce nor HCV-positive donor status significantly decreased patient and graft survival rates by Kaplan-Meier analysis. However, use of HCV-positive dono rs reduced the median time of recurrence to 22.9 months compared with 35.7 months after transplantation of HCV-negative livers. Stratification of pati ents into five subgroups, based on time of recurrence, revealed that early HCV recurrence was associated with significantly increased rates of patient death and graft loss. Donor, recipient, and operative variables that may a ffect OLT outcome were analyzed. On univariate analysis, recipient age, ser um creatinine, donor length of hospital stay, donor female gender, United N etwork for Organ Sharing (UNOS) status of recipient, and presence of hepato cellular cancer affected the outcome of OLT. Elevation of pretransplant HCV RNA was associated with an increased risk of graft loss. Of 15 variables c onsidered by multivariate Cox regression analysis, recipient age, UNOS stat us, donor gender, and log creatinine were simultaneous significant predicto rs for patient survival. Simultaneously significant factors for graft failu re included log creatinine, log alanine transaminase, log aspartate transam inase, UNOS status, donor gender, and warm ischemia time. These variables w ere therefore entered into prognostic models for patient and graft survival . Conclusion The earlier the recurrence of HCV, the greater the impact on pat ient and graft survival. The use of HCV-positive donors may accelerate HCV recurrence, and they should be used judiciously. Patient survival at the ti me of transplantation is predicted by donor gender, UNOS status, serum crea tinine, and recipient age. Graft survival is affected by donor gender, warm ischemia time, and pretransplant patient condition. The authors' current s urvival prognostic models require further multicenter validation.