Are short-term complications associated with poor allograft and patient survival after liver transplantation? A systematic review of the literature and expert panel recommendations.Alconchel, F., et al.
Clinical Transplantation 2022; 36(10): e14704.
This study aimed to investigate the impact of short-term complications on patient and graft survival following liver transplantation.
A literature search was conducted on Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. Studies were selected by two independent reviewers. The quality of evidence and strength of recommendations were rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.
32 studies were included in the review.
The outcomes of interest included patient survival, graft survival, posttransplant complications, and short-term outcomes including morbidity, mortality, length of intestive care unit (ICU) or hospital stay.
This systematic review identified a total of 32 articles exploring the association between short-term complications and graft and patient survival following liver transplantation. All included studies were observational, 18 comparative and 14 non-comparative. The studies assessed found AKI, biliary complications, and early allograft disfunction (EAD) have significant effect on graft and patient survival. There was a moderate quality of evidence based on the majority of included studies that both graft and patient survival was lower when AKI, EAD and biliary complications were present, with the recommendation that efforts should be made to reduce these to improve outcomes. They found a low quality of evidence, from only 4 of the included studies that EAD was associated with AKI, CKD, donor age, donor BMI, DCD donor, steatosis, and WIT. A moderate quality of evidence from 12 studies associating biliary complications with cholestatic liver disease, roux-en-y anastomosis, low portal vein flow, high-grade portal vein thrombosis, presence of stent or t-tube and raised donor risk index. They also found a moderate quality of evidence from 7 studies associating AKI with raised BMI, prolonged IVC clamping, long CIT and massive transfusion (>10 units). The authors recommend that patients with any of the risk factors associated with key complications (AKI, EAD and biliary complications) should be considered pre-operatively and monitored closely. The authors present a comprehensive systematic review of the relevant literature, while all observational studies, there is a high volume of patients within these studies >25,000 patients. The key outcomes of graft and patient survival are present in nearly all studies. The evidence included is of sufficient quality to associate the short-term complications of AKI, EAD and biliary compilations with reduced graft and patient survival as they intended. As such, the recommendations to take steps to reduce these is a sensible one, however, the evidence of associated risk factors is of lower quality and thus it is difficult for a clinician to know clearly what factors to be weary of. A meta-analysis could have been of value but given the lack of randomised studies included to level of evidence would have remained the same. Overall, the studies highlight the key complications that could result in poorer outcomes and some risk factors associated with these complications.