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The Evolution of Redo Liver Transplantation Over 35-years: Analysis of 654 Consecutive Adult Liver Re-Transplants at a Single Center
Daisuke Noguchi1, Ramsey Ugarte1, Samer Ebaid1, Vatche Agopian1, Hasan Yersiz1, Sammy Saab2, Steven Han2, Mohamed M. El Kabany2, Gina Choi2, Akshey Shetty2, Jasleen Singh2, Christopher Wray3, Igor Barjaktarevic2, Ronald W. Busuttil1, Douglas G. Farmer1, Fady M. Kaldas*1
1Surgery, University of California Los Angeles, Los Angeles, CA; 2Medicine, University of California Los Angeles, Los Angeles, CA; 3Anesthesiology, University of California Los Angeles, Los Angeles, CA

Objectives: Despite the durability of liver transplantation (LT), graft failure affects up to 22% of LT recipients. Acuity-based allocation, organ shortage, and a scarcity of data have fueled skepticism of liver Re-Transplantation (Re-LT), drastically and indiscriminately limiting access to this life saving intervention. We aimed to: 1) analyze a 35-year single center experience with Re-LT, 2) evaluate outcomes pre and post-MELD, 3) examine high vs. low MELD impact on outcomes, and 4) identify risk factors for early mortality in the post-MELD era.

Methods: All consecutive adult Re-LTs done at a single institution were analyzed (1984- 2021). Comparisons were made pre- and post-implementation of MELD for organ allocation (1984-2001 vs. 2002-2021). In the post-MELD era, comparative and multivariable regression analyses assessed 131 perioperative factors based on era and acuity (MELD <35 vs. ≥35), and identified predictors of early (death within 12 mo.) mortality.

Results: 654 consecutive adult Re-LT’s were performed in 590 recipients over the study period (57% n=372 Pre-MELD and 43% n=282 Post-MELD). The most common indications were chronic rejection and primary non-function (PNF). Survival was best in Re-LT for portal vein thrombosis and chronic rejection and worst for delayed non-function (DNF) (graft failure 7-30 days). 89% of patients had 1 previous LT, while 11% had 2 or more. Compared to pre-MELD Re-LTs, more post-MELD Re-LTs were for chronic rejection and recurrent disease. Post-MELD Re-LT patients were older (53 vs. 48y.o., p=0.001), had higher MELD (35 vs. 31, p=0.01), longer wait times (14 vs.3 days P<0.001), longer Pre-op hospital stay (17 vs. 12 days, P<0.01), more comorbidities (HTN, CAD, DM), and were more likely to require pre-op dialysis, intra-op pRBC transfusion (5400 vs. 2400ml, <0.001) and abdominal packing (31% vs. 3%, <0.001). However, Post-MELD Re-LT patients had superior 1- 3, and 5-year survival (74%, 66% and 61% vs. 50%, 45%, and 41%, p<0.001) (Fig 1), lower in-hospital mortality (28% vs. 48% <0.001), and lower rejection rates (acute: 17% vs. 35%, <0.001, chronic: 9% vs. 31%, <0.001). Of all post-MELD Re-LTs, 52% had a MELD ≥ 35, and similar patient survival to MELD <35 Re-LTs (71%, 65%, and 62% vs. 76%, 67%, and 60% at 1,3, and 5 years respectively p=0.774) (Fig 2A). Multivariate Cox regression of 47 pre-operative variables identified recipient BMI ≥30 (HR 1.051, 95%CI 1.007-1.097, p=0.023), CAD (HR 4.761, 95%CI 2.410-9.405, p<0.001), and pre-op mechanical ventilation (HR 3.224, 95%CI 1.749-5.945, p<0.001) as independent risk factors for early mortality (Fig 2B).

Conclusions: This represents the world’s largest single center Re-LT experience. Despite the increased acuity and complexity of Re-LT patients, post-MELD outcomes have greatly improved. With careful patient selection and risk stratification, these results support the efficacy and survival benefit of Re-LT in an acuity-based allocation environment.

Figure 1

Figure 2

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