ESOT 2013 Report – Retransplantation of abdominal organs

Re-transplantation is the only option available for salvaging a failed abdominal graft. As the outcomes after primary transplantations continue to improve, even with the increasing use of extended-criteria donors, the demand for re-transplantation is set to increase. In a debate over the pros and cons of retransplantation of abdominal organs, especially liver retransplantations, the two opponents argued that whilst retransplantation does make a difference in terms of long-term survival, listing for retransplantation is a burden on the waiting list and denies other patients their chance of having a primary transplantation.

 

Stating the case in favour of retransplantation in the case of liver transplantation, Mr Darius Mirza from Birmingham in the UK reminded the audience that as many as one in five recipients present with irreversible graft loss after liver transplantation [1,2], most often within three months of the primary transplantation. At Mr Mirza’s own centre in Birmingham, one sixth of all liver transplantations is a re-graft. Back in the 1980s, acute rejection was the most common indication for retransplantation – improved immunosuppressive protocols have changed this and the most common indications for retransplantation today include, in addition to primary non-function, hepatic artery thrombosis (HAT), biliary complications, and hepatitis C infection.

 

Registry data from Birmingham and other centres shows that the long-term success of liver retransplantation can be predicted by multiple risk factors, including recipient age over 55 years and donor age over 45 years, recipient MELD score greater than 27, a history of previous liver transplantation (ie multiple retransplantations), and retransplantation between 15 and 180 days from the primary procedure [3]. Mr Mirza stressed that by selecting recipients based on these risk factors, it is possible to achieve patient and graft survival rates that are comparable to those after primary liver transplantation; the exception is retransplantation due to hepatitis C infection, where mortality rates remain comparatively high and unlikely to improve until better antiviral therapies become available [4,5].

 

At the heart of the case against retransplantation of abdominal organs, as argued by Professor Wolf Bechstein from Frankfurt, Germany, lies the fact that retransplantations are associated with inferior long-term outcomes and thus represent a less efficient and utility-driven use of available organs compared with primary transplantations, which will effectively deny other and perhaps more deserving patients the chance of having their primary transplantation. Organs for transplantation are a scarce resource that should be allocated based on strict principles of equity (everyone on the waiting list have an equal opportunity to receive a graft), efficiency (prevention of waste) and utility (maximise the benefit to the recipient) [6]. A central aspect of the allocation process is to have objective and validated criteria for not only the utility but also for futility, ie when transplantation should not be an option [7]. Numerous analyses have shown that retransplantation is a significant risk factor for poor outcomes [8,9]. Various scoring systems have been proposed to allow quantification of the risk and selection of patients for retransplantation, including the Rosen score which takes into account the patient’s age, bilirubin, creatinine, United Network for Organ Sharing (UNOS) status, and cause of graft failure and which predicts the likelihood of survival to a high degree of certainty [10]. Professor Bechstein suggested that applying such scores may improve the chances of success in retransplantation – unrestricted retransplantations, however, constitute an unacceptable waste of precious organs and should be avoided.

 

References

1. Adam, R., et al., Normalised intrinsic mortality risk in liver transplantation: European Liver Transplant Registry study. Lancet, 2000. 356(9230): p. 621-7.

2.Markmann, J.F., et al., Long-term survival after retransplantation of the liver. Ann Surg, 1997. 226(4): p. 408-18; discussion 418-20.

3.Hong, J.C., et al., Predictive index for long-term survival after retransplantation of the liver in adult recipients: analysis of a 26-year experience in a single center. Ann Surg, 2011. 254(3): p. 444-8; discussion 448-9.

4.Roayaie, S., et al., Results of retransplantation for recurrent hepatitis C. Hepatology, 2003. 38(6): p. 1428-36.

5.Jain, A., et al., Survival outcome after hepatic retransplantation for hepatitis C virus-positive and -negative recipients. Transplant Proc, 2005. 37(7): p. 3159-61.

6.Baskin-Bey, E.S. and S.L. Nyberg, Matching graft to recipient by predicted survival: can this be an acceptable strategy to improve utilization of deceased donor kidneys? Transplant Rev (Orlando), 2008. 22(3): p. 167-70.

7.Neuberger, J., Rationing life-saving resources–how should allocation policies be assessed in solid organ transplantation. Transpl Int, 2012. 25(1): p. 3-6.

8.Doyle, H.R., et al., Hepatic Retransplantation–an analysis of risk factors associated with outcome. Transplantation, 1996. 61(10): p. 1499-505.

9.Busuttil, R.W., et al., Analysis of long-term outcomes of 3200 liver transplantations over two decades: a single-center experience. Ann Surg, 2005. 241(6): p. 905-16; discussion 916-8.

10.Rosen, H.R., J.P. Madden, and P. Martin, A model to predict survival following liver retransplantation. Hepatology, 1999. 29(2): p. 365-70