Risk Factors For Poor Prognosis Following Liver Transplantation In Recipients With Hepatitis B Virus Related Acute-on-chronic Liver Failure

Chapter I Factors Prognostic of Survival in Liver Transplant Recipients with Hepatitis B Virus Related Acute-on-Chronic Liver FailureAim:To analyze the prognostic factors of hepatitis B related acute-on-chronic liver failure(HBV-ACLF)patients after liver transplantation(LT),and to determine the scoring system(MELD,MELD-Na,CLIF-C ACLF,COSSH-ACLF and COSSH-ACLF IIs)optimal for assessing prognosis in HBV-ACLF patients following LT.Methods:A total of 323 HBV-ACLF patients who underwent LT in our center from January 2015 to June 2020 were included.According to the Chinese Group on the Study of Severe Hepatitis B-ACLF(COSSH-ACLFs),the323 LT recipients with HBV-ACLF included in this study were divided into three grades based on the number of failed organs,with 112,146,and 65 patients classified as having HBV-ACLF grades 1,2,and 3,respectively.Outcomes in these three groups were compared.The patients were divided into survived group and died group according to the survival or death status at 1 year after LT.Clinical data were compared between the two groups.The receiver operating curve(ROC)and Youden index were used to analyze the best cut-off value of the most significant single factors.Cox regression analysis was further performed on significant univariate factors based on the cut-off values to explore the prognostic factors of HBV-ACLF patients after LT.Receiver operating curve(ROC)and area under curve(AUC)were used to evaluate the prognostic value of all scoring systems in patients with HBV-ACLF following LT.Results:Recipients with HBV-ACLF 1,HBV-ACLF 2,and HBV-ACLF 3were significant differences in body mass index(BMI),total serum creatinine concentration,international normalized ratio(INR),white blood cell(WBC),neutrophil,hemoglobin concentrations,platelet counts,with all of these parameters being significantly worse in the HBV-ACLF3 than the other two groups.There was no statistical difference in donor clinical data among the three groups.Survival analysis showed that 1-year survival rate of HBV-ACLF grade 3 patients after LT was significantly lower than HBV-ACLF grade 1 and HBV-ACLF grade 2(80.0%vs.93.8%and 80.0%vs.91.8%,p=0.0063).Cox analysis showed that the recipient age>53 years(hazard ratio[HR]3.713),WBC counts>8.6×10~9/L(HR 4.544),HBV-ACLF grade 3(HR 2.729),cold ischemia time>8.5 h(HR 2.867)were the risk factors for 1-year survival following LT in HBV-ACLF patients(p<0.01).Comparisons of pre-transplant scores showed that CLIF-Consortium-ACLF score was superior to COSSH-ACLF,MELD-Na,and MELD scores in predicting1-year overall survival(OS)in these patients.Conclusions:Age>53 years,WBC counts>8.6×10~9/L,HBV-ACLF grade 3,and cold ischemia time>8.5 hours are independently prognostic of OS in LT recipients with HBV-ACLF.CLIF-Consortium-ACLF score is superior to other scoring methods in predicting 1-year OS in these patients.Chapter II Risk Factors for Early Allograft Dysfunction in Patients with Hepatitis B Virus Related Acute-on-chronic Liver Failure Following Deceased Liver TransplantationAim:To explore risk factors associated with EAD in HBV-ACLF recipients undergoing deceased LT.Methods:A single-center,retrospective study of EAD based on data from January 2015 to June 2020.Of the study,323 recipients with HBV-ACLF and 445 recipients with HBV-No-ACLF were included.Groups were compared using Kruskal–Wallis tests,unpaired Student’s t-tests,and Pearson’s Chi-squared or Fisher’s exact tests,as warranted.Risk factors significantly affecting patient survival were determined and included in a logistic regression model analysis.1-year survival rates after LT were analyzed by the Kaplan–Meier method.Result:The incidence of EAD in HBV-ACLF recipients was significantly higher than that in HBV-No-ACLF recipients(39.3%vs.21.1%,p<0.001).HBV-ACLF recipients who developed EAD had lower 90-,180-,and 360-day patient survival rate as compared with those who did not develop EAD(89.0%vs.98.0%,82.7%vs.97.5%and 80.3%vs.96.4%,respectively,p<0.001).Pre-LT kidney failure(OR=2.644,95%CI:1.019-6.864,p=0.046),Pre-LT coagulation failure(OR=2.162,95%CI:1.291-3.621,p=0.003)and operative time(OR=1.005,95%CI:1.002-1.008,p=0.003)were independently risk factors of EAD in HBV-ACLF recipients.There was a synergistic effect of EAD and pre-LT kidney/coagulation failure on HBV-ACLF recipients 1-year survival rates.Conclusion:Pre-LT kidney/coagulation failure and operative time were independently risk factors of EAD in patients with HBV-ACLF following decease LT.The combination of EAD and pre-LT kidney/coagulation failure of recipients was significantly associated with the poor patient survival after LT.