Observational Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 28, 2015; 21(20): 6296-6303
Published online May 28, 2015. doi: 10.3748/wjg.v21.i20.6296
Outcomes of liver transplantation for end-stage biliary disease: A comparative study with end-stage liver disease
Yan-Hua Lai, Wei-Dong Duan, Qiang Yu, Sheng Ye, Nian-Jun Xiao, Dong-Xin Zhang, Zhi-Qiang Huang, Zhan-Yu Yang, Jia-Hong Dong
Yan-Hua Lai, Wei-Dong Duan, Qiang Yu, Sheng Ye, Nian-Jun Xiao, Dong-Xin Zhang, Zhi-Qiang Huang, Jia-Hong Dong, Hospital and Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
Zhan-Yu Yang, Institute of Hepatobiliary Surgery, South West Hospital, Third Military Medical University, Chongqing 400038, China
Author contributions: Dong JH and Yang ZY proposed the study; Lai YH and Dong JH performed the research and wrote the first draft; all authors contributed to the design and interpretation of the study and to further drafts; Dong JH and Yang ZY are the guarantors.
Supported by National Science and Technology Major Project for Infectious Diseases of China, No. 2012ZX10002-017.
Ethics approval: The study was reviewed and approved by the Chinese PLA General Hospital Institutional Review Board.
Informed consent: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest: The authors declare that they have no conflicts of interest concerning this article.
Data sharing: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jia-Hong Dong, MD, PhD, FACS, Hospital and Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing 100853, China. dongjh301@163.com
Telephone: +86-10-66938030 Fax: +86-10-68241383
Received: November 30, 2014
Peer-review started: November 30, 2014
First decision: January 8, 2015
Revised: February 7, 2015
Accepted: March 30, 2015
Article in press: March 31, 2015
Published online: May 28, 2015

AIM: To evaluate the outcomes of patients with end-stage biliary disease (ESBD) who underwent liver transplantation, to define the concept of ESBD, the criteria for patient selection and the optimal operation for decision-making.

METHODS: Between June 2002 and June 2014, 43 patients with ESBD from two Chinese organ transplantation centres were evaluated for liver transplantation. The causes of liver disease were primary biliary cirrhosis (n = 8), cholelithiasis (n = 8), congenital biliary atresia (n = 2), graft-related cholangiopathy (n = 18), Caroli’s disease (n = 2), iatrogenic bile duct injury (n = 2), primary sclerosing cholangitis (n = 1), intrahepatic bile duct paucity (n = 1) and Alagille’s syndrome (n = 1). The patients with ESBD were compared with an end-stage liver disease (ESLD) case control group during the same period, and the potential prognostic values of multiple demographic and clinical variables were assessed. The examined variables included recipient age, sex, pre-transplant clinical status, pre-transplant laboratory values, operation condition and postoperative complications, as well as patient and allograft survival rates. Survival analysis was performed using Kaplan-Meier curves, and the rates were compared using log-rank tests. All variables identified by univariate analysis with P values < 0.100 were subjected to multivariate analysis. A Cox proportional hazard regression model was used to determine the effect of the study variables on outcomes in the study group.

RESULTS: Patients in the ESBD group had lower model for end-stage liver disease (MELD)/paediatric end-stage liver disease (PELD) scores and a higher frequency of previous abdominal surgery compared to patients in the ESLD group (19.2 ± 6.6 vs 22.0 ± 6.5, P = 0.023 and 1.8 ± 1.3 vs 0.1 ± 0.2, P = 0.000). Moreover, the operation time and the time spent in intensive care were significantly higher in the ESBD group than in the ESLD group (527.4 ± 98.8 vs 443.0 ± 101.0, P = 0.000, and 12.74 ± 6.6 vs 10.0 ± 7.5, P = 0.000). The patient survival rate in the ESBD group was not significantly different from that of the ESBD group at 1, 3 and 5 years (ESBD: 90.7%, 88.4%, 79.4% vs ESLD: 84.9%, 80.92%, 79.0%, χ2 = 0.194, P = 0.660). The graft-survival rates were also similar between the two groups at 1, 3 and 5 years (ESBD: 90.7%, 85.2%, 72.7% vs ESLD: 84.9%, 81.0%, 77.5%, χ2 = 0.003, P = 0.958). Univariate analysis identified MELD/PELD score (HR = 1.213, 95%CI: 1.081-1.362, P = 0.001) and bleeding volume (HR = 0.103, 95%CI: 0.020-0.538, P = 0.007) as significant factors affecting the outcomes of patients in the ESBD group. However, multivariate analysis revealed that MELD/PELD score (HR = 1.132, 95%CI: 1.005-1.275, P = 0.041) was the only negative factor that was associated with short survival time.

CONCLUSION: MELD/PELD criteria do not adequately measure the clinical characteristics and staging of ESBD. The allocation system based on MELD/PELD criteria should be re-evaluated for patients with ESBD.

Keywords: Liver transplantation, End-stage biliary disease, Model for end-stage liver disease, Paediatric end-stage liver disease, Complication

Core tip: In this work, we evaluated the clinical characteristics of end-stage biliary disease (ESBD) and demonstrated that ESBD comprises a subset of disease that significantly differs from end-stage liver disease (ESLD), which is caused by hepatitis and cirrhosis. However, previous research on ESBD has been classified within the category of ESLD. The model for end-stage liver disease (MELD) does not adequately measure the clinical characteristics and stages of patients with ESBD before liver transplantation. Patients with ESBD would be less likely to receive priority for liver transplantation, and thus, the allocation system based on the MELD score is inappropriate and should be re-evaluated for patients with ESBD. In addition, the concept of ESBD and the indications for liver transplantation are established in this paper.