Retransplantation in Late Hepatic Artery Thrombosis: Graft Access and Transplant Outcome

• Main Authors: Bettina M. Buchholz, MD, FEBS, Shakeeb Khan, MD, FRCS, Miruna D. David, LRCPS, MRCP, Bridget K. Gunson, John R. Isaac, MBBS, MD, FRCS, Keith J. Roberts, MD, FRCS, Paolo Muiesan, MD, FRCS, Darius F. Mirza, MBBS, MD, FRCS, Dhiraj Tripathi, MD, FRCP, M. Thamara P.R. Perera, MBBS, MS, FEBS, MD, FRCS
• Format: Article
• Language: English
• Published: Wolters Kluwer 2017-08-01
• Series: Transplantation Direct
• Online Access: http://journals.lww.com/transplantationdirect/fulltext/10.1097/TXD.0000000000000705

Background. Definitive treatment for late hepatic artery thrombosis (L-HAT) is retransplantation (re-LT); however, the L-HAT–associated disease burden is poorly represented in allocation models. Methods. Graft access and transplant outcome of the re-LT experience between 2005 and 2016 was reviewed with specific focus on the L-HAT cohort in this single-center retrospective study. Results. Ninety-nine (5.7%) of 1725 liver transplantations were re-LT with HAT as the main indication (n = 43; 43%) distributed into early (n = 25) and late (n = 18) episodes. Model for end-stage liver disease as well as United Kingdom model for end-stage liver disease did not accurately reflect high disease burden of graft failure associated infections such as hepatic abscesses and biliary sepsis in L-HAT. Hence, re-LT candidates with L-HAT received low prioritization and waited longest until the allocation of an acceptable graft (median, 103 days; interquartile range, 28-291 days), allowing for progression of biliary sepsis. Balance of risk score and 3-month mortality score prognosticated good transplant outcome in L-HAT but, contrary to the prediction, the factual 1-year patient survival after re-LT was significantly inferior in L-HAT compared to early HAT, early non-HAT and late non-HAT (65% vs 82%, 92% and 95%) which was mainly caused by sepsis and multiorgan failure driving 3-month mortality (28% vs 11%, 16% and 0%). Access to a second graft after a median waitlist time of 6 weeks achieved the best short- and long-term outcome in re-LT for L-HAT (3-month mortality, 13%; 1-year survival, 77%). Conclusions. Inequity in graft access and peritransplant sepsis are fundamental obstacles for successful re-LT in L-HAT. Offering a graft for those in need at the best window of opportunity could facilitate earlier engrafting with improved outcomes.