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Liver Dysfunction Associated with Other Organ Dysfunction

Patients awaiting liver transplantation who also suffer from coronary disease, diabetes, chronic obstructive pulmonary disease (COPD), connective tissue disease or renal insufficiency may face poorer survival after liver transplantation. These conditions have been incorporated into a new modified comorbidity index which helps predict post-transplant survival.

The findings are published in the November 2007 issue of Liver Transplantation.
Determining who receives the limited supply of donor organs is one of the greatest challenges facing the transplant community. Severity of illness is the main criteria for hopeful liver recipients; however it is not the only factor that influences post-transplant survival. In other medical fields, co-morbidities have been considered as relevant predictors of survival, but never among the liver transplant community.

To address this paucity in the literature, researchers, led by Michael Volk, M.D., M.S. of the Department of Gastroenterology at the University of Michigan Health System sought to determine if the Charlson Comorbidity Index (CCI) would predict long-term survival after liver transplantation.

They conducted a retrospective study of 624 patients who underwent liver transplantation at U-M Hospital between 1994 and 2005 (to obtain a median follow-up of 5 years). They collected demographic, clinical and laboratory data for each patient, but focused on the nine comorbidities comprising the Charlson Comorbidity Index. These include congestive heart failure, coronary artery disease, diabetes mellitus, peripheral vascular disease, cerebral vascular accident, COPD, connective tissue disease, renal insufficiency and malignancy.

Forty percent of the patients had one or more comorbidities prior to transplantation. After statistical analysis, the researchers found that coronary disease, diabetes, COPD, connective tissue disease, and renal insufficiency were all independent predictors of poorer post-transplant survival. The researchers then recalibrated the CCI using this information, to create the CCI-OLT. This new index predicted post-transplant survival equally as well as the other available model which uses recipient characteristics like age, BMI, and etiology of liver disease.

“Our study shows that comorbidities play an important role in determining post-transplant survival,” the authors report. “This information will be useful when counseling patients with comorbidities about outcomes after transplantation.”

The study was limited by the fact that it was a single center, retrospective cohort study, and the researchers were not able to determine to what extent the comorbidities were manifestations of advanced liver disease. Still, the researchers demonstrated the usefulness of the modified comorbidity index for predicting post-liver-transplant. “In the future, the addition of comorbidities to multivariable models may be useful in developing new allocation algorithms which incorporate the likelihood of post-transplant survival,” they conclude.

An accompanying editorial, by Richard Freeman of the New England Medical Center, lauds the authors for their novel approach, though he cautioned that it remains to be seen if these results can be replicated. He writes that it is also somewhat disappointing that the CCI-OLT index was no better at predicting outcome than most of the other models already published.

Still, he reports, the mathematical model presented by Volk and colleagues, “can help estimate ahead of time what might be correct choices for patients when the call comes in the middle of the night.”

Editors note: May we suggest that patients with multiple disease states of unknown etiology, suffer from an underlying mitochondrial dysfunction, causing ATP deficiency which effects all organ function.


Press Release November 2, 2007 University of Michigan Health System

“A modified Charlson Comorbidity Index for predicting survival after liver transplantation.” Volk; Michael; Hernandez, Jose; Lok, Anna; Marrero, Jorge. Liver Transplantation; November 2007.

Editorial: “Predicting the Future?” Freeman, Richard. Liver Transplantation; November 2007.

Key concepts: liver disease, liver transplant, coronary disease, diabetes, chronic obstructive pulmonary disease (COPD), connective tissue disease, renal insufficiency