Independent Risk Factors for Massive Ascites After Living Donor Liver Transplantation in Adults C. Li, Q. Lu, J. Luo, and Z. Zhang ABSTRACT Objectives. This study sought to define the perioperative recipient and donor factors that contribute to the occurrence of massive ascites after living donor liver transplantation (LDLT) in adults. Methods. A retrospective review of medical records and computerized databases was performed, and 105 adult patients who underwent LDLT from 2005 to 2011 in the West China Hospital, Sichuan University, were included. Patients were divided into group 1 (n ¼ 27, massive ascites defined as >7000 mL of ascitic fluid produced during the first 7 days after LDLT) or group 2 (n ¼ 78, no massive ascites). Perioperative recipient and donor factors were assessed using a univariate analysis followed by 2 logistic regression analyses. Results. The recipients’ median age was 44 years (range, 27 to 69 years), and the maleto-female ratio was 92:13. Massive ascites developed in 27 patients (25.7%). The average amount of ascites in group 1 and group 2 patients within the first 7 postoperative days was 11,285 mL and 3311 mL, respectively. The univariate analysis showed that recipient’s age, primary liver disease, preoperative MELD score, Child-Pugh score, operating time, postoperative sequential organ failure assessment (SOFA) score, postoperative total bilirubin, right hepatic vein graft diameter, and hepatic portal vein graft diameter were significantly different between the 2 groups (P < .05). The 2 logistic regressions showed that the Child-Pugh score, operating time, and right hepatic vein graft diameter were independent risk factors for massive ascites after LDLT. Conclusion. It is important to improve the perioperative liver function and portal hypertension and to shorten operating time to reduce massive ascites after LDLT.

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IVER TRANSPLANTATION has become the most effective treatment for end-stage liver disease since 1997, when Lo et al. reported the first case of right lobe adult-to-adult living donor liver transplantation [1], a procedure that has resulted in excellent survival and substantial improvement in the patient’s quality of life [2,3]. There have been 24,635 liver transplants performed in China between January 1, 1980, and July 9, 2013, of which 1777 were living donor liver transplants, according to the China Liver Transplant Registry [4]. Ascites is a common complication after liver transplantation [5e8], with small to moderate amounts of ascitic fluid often observed in the early postoperative period and usually disappearing within a few days [9]. The incidence of postoperative massive ascites after liver transplantation was 7% to 23.7% [5,6]; the patient’s prognosis is worse with massive ascites and mortality tends ª 2014 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 883e887 (2014)

to be higher in these patients [6,7]. To our knowledge, there are few studies that have investigated the independent risk factors for massive ascites after the living donor liver transplantation (LDLT) in adults. We observed that patients who underwent LDLT had a higher incidence of massive ascites than did patients who received a deceased donor liver transplantation. Thus, we retrospectively reviewed the medical records and computerized databases of patients who underwent LDLT from 2005 to 2011 in our hospital. By analyzing the perioperative donor and recipient From the Department of ICU, West China Hospital, Sichuan University, Chendu 610041, China. Address reprint requests to Zhongwei Zhang, West China Hospital, Sichuan University, Chendu 610041, China. E-mail: [email protected] 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.048 883

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characteristics, we explored the independent risk factors for massive ascites in patients who underwent LDLT [5e7]. PATIENTS AND METHODS This is a retrospective review of 105 liver transplantations performed in 105 adult patients who survived more than 7 days after surgery at the Sichuan University from 2005 to 2011. Patients who simultaneously received other organs (eg, a kidney) in addition to the LDLT were not included in this study. Clinical data were obtained by retrospective review of medical records and computerized databases. To identify the possible factors related to the development of massive ascites, the following preoperative recipient variables were analyzed: age, sex, weight, primary liver disease, MELD score, Child-Pugh score, renal function test results, and portal vein thrombosis. Intraoperative recipient variables included operating time, inferior vena cava occlusion time, and whether or not the hepatic vein was bypassed. Postoperative recipient variables included the sequential organ failure assessment (SOFA) score (day 1 post-LDLT), APACHE II score (day 1 post-LDLT), net fluid intake (the total intake minus the total output during the first 7 days after LDLT ), total colloidal intake (during the first 7 days after LDLT), total albumin intake (during the first 7 days after LDLT), postoperative liver and renal function test results (taken day 3 postLDLT), portal vein thrombosis (during the first 7 days after LDLT), the portal vein diameter days 3 and 7 post-LDLT, and portal vein blood flow peak velocity on days 3 and 7 post-LDLT. Donor factors that were analyzed included sex, age, graft weight-to-recipient weight ratio, graft volumes-to-standard liver volume ratio, donor liver quality, portal vein graft diameter, hepatic artery graft diameter, and right hepatic vein graft diameter. In addition, we explore the impact of massive ascites on the duration of mechanical ventilation, duration of time in the intensive care unit (ICU), and length of hospital stay. Massive ascites was defined as the production of ascitic fluid >7000 mL during the first 7 days after LDLT, as assessed by loss of ascitic fluid through drain tubes, surgical wounds, or paracentesis. Patients were placed into either group 1 (n ¼ 27, massive ascites) or group 2 (n ¼ 78, no massive ascites) based on this definition.

STATISTICS

Normally distributed quantitative variables were compared using the Student t test. Comparison of nonnormally distributed quantitative variables and level variables were made using the rank sum test. Qualitative variables were compared using the c2 test. Quantitative variables are reported as mean  standard deviation (SD). Qualitative variables are reported as the median (range), and categorical variables are summarized using proportions. Differences determined using a univariate analysis at a level of P < .1 were followed by a 2-logistic-regression analysis. Statistical significance is established at P < .05. RESULTS Patient Population

There were 105 patients enrolled into this study, and the male-to-female ratio was 92:13. The median age of the 105 recipients enrolled into this study was 44 years (range, 27 to

LI, LU, LUO ET AL

69 years). The median age of patients in group 1 (massive ascites) and group 2 (no massive ascites) were 41  6 years and 45  8 years, respectively. Overall, the primary disease was cirrhosis (51 patients), liver tumors (25 patients), and a combination of the 2 (23 patients). The median preoperative MELD score and the Child-Pugh score for the 105 patients were 10.9  7.6 and 8.3  2.6, respectively. Massive ascites developed in 27 patients (25.7%), and the male-tofemale ratio in this group was 25:2. The average amount of ascites of group 1 (massive ascites) and group 2 (no massive ascites) within the first 7 postoperative days was 11285 mL and 3311 mL, respectively. Factors Associated with Massive Ascites

Univariate analysis of risk factors for massive ascites revealed that recipient age, primary disease, MELD score, Child-Pugh score, and operating time were risk factors, with P values of .044, .017, .005,

Independent risk factors for massive ascites after living donor liver transplantation in adults.

This study sought to define the perioperative recipient and donor factors that contribute to the occurrence of massive ascites after living donor live...
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