The role of the comprehensive complication index for the prediction of survival after liver transplantation

Quirino Lai, Fabio Melandro, Greg Nowak, Daniele Nicolini, Samuele Iesari, Elisa Fasolo, Gianluca Mennini, Antonio Romano, Federico Mocchegiani, Kevin Ackenine, Marina Polacco, Laura Marinelli, Olga Ciccarelli, Giacomo Zanus, Marco Vivarelli, Umberto Cillo, Massimo Rossi, Bo-Göran Ericzon, Jan Lerut, Quirino Lai, Fabio Melandro, Greg Nowak, Daniele Nicolini, Samuele Iesari, Elisa Fasolo, Gianluca Mennini, Antonio Romano, Federico Mocchegiani, Kevin Ackenine, Marina Polacco, Laura Marinelli, Olga Ciccarelli, Giacomo Zanus, Marco Vivarelli, Umberto Cillo, Massimo Rossi, Bo-Göran Ericzon, Jan Lerut

Abstract

In the last years, several scoring systems based on pre- and post-transplant parameters have been developed to predict early post-LT graft function. However, some of them showed poor diagnostic abilities. This study aims to evaluate the role of the comprehensive complication index (CCI) as a useful scoring system for accurately predicting 90-day and 1-year graft loss after liver transplantation. A training set (n = 1262) and a validation set (n = 520) were obtained. The study was registered at https://www.ClinicalTrials.gov (ID: NCT03723317). CCI exhibited the best diagnostic performance for 90 days in the training (AUC = 0.94; p < 0.001) and Validation Sets (AUC = 0.77; p < 0.001) when compared to the BAR, D-MELD, MELD, and EAD scores. The cut-off value of 47.3 (third quartile) showed a diagnostic odds ratio of 48.3 and 7.0 in the two sets, respectively. As for 1-year graft loss, CCI showed good performances in the training (AUC = 0.88; p < 0.001) and validation sets (AUC = 0.75; p < 0.001). The threshold of 47.3 showed a diagnostic odds ratio of 21.0 and 5.4 in the two sets, respectively. All the other tested scores always showed AUCs < 0.70 in both the sets. CCI showed a good stratification ability in terms of graft loss rates in both the sets (log-rank p < 0.001). In the patients exceeding the CCI ninth decile, 1-year graft survival rates were only 0.7% and 23.1% in training and validation sets, respectively. CCI shows a very good diagnostic power for 90-day and 1-year graft loss in different sets of patients, indicating better accuracy with respect to other pre- and post-LT scores.Clinical Trial Notification: NCT03723317.

Keywords: Allograft dysfunction; Graft survival; MELD; Retransplantation; Survival prediction.

Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Fig. 1
Fig. 1
a Training set: 1-year graft survival rates according to the CCI risk strata. b Validation set: 1-year graft survival rates according to the CCI risk strata

References

    1. Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33:464–470. doi: 10.1053/jhep.2001.22172.
    1. Freeman RB. A decade of model for end-stage liver disease: lessons learned and need for re-evaluation of allocation policies. Curr Opin Organ Transplant. 2012;17:211–215. doi: 10.1097/MOT.0b013e3283534dde.
    1. Silberhumer GR, Hetz H, Rasoul-Rockenschaub S, et al. Is MELD score sufficient to predict not only death on waiting list, but also post-transplant survival? Transplant Int. 2006;19:275–281. doi: 10.1111/j.1432-2277.2006.00250.x.
    1. Klein KB, Stafinski TD, Menon D. Predicting survival after liver transplantation based on pre-transplant MELD score: a systematic review of the literature. PLoS ONE. 2013;8:e80661. doi: 10.1371/journal.pone.0080661.
    1. Halldorson JB, Bakthavatsalam R, Fix O, et al. D-MELD, a simple predictor of post liver transplant mortality for optimization of donor/recipient matching. Am J Transplant. 2009;9:318–326. doi: 10.1111/j.1600-6143.2008.02491.x.
    1. Dutkowski P, Oberkofler CE, Slankamenac K, et al. Are there better guidelines for allocation in liver transplantation? A novel score targeting justice and utility in the model for end-stage liver disease era. Ann Surg. 2011;254:745–753. doi: 10.1097/SLA.0b013e3182365081.
    1. Olthoff KM, Kulik L, Samstein B, et al. Validation of a current definition of early allograft dysfunction in liver transplant recipients and analysis of risk factors. Liver Transplant. 2010;16:943–949. doi: 10.1002/lt.22091.
    1. Slankamenac K, Graf R, Barkun J, et al. The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg. 2013;258:1–7. doi: 10.1097/SLA.0b013e318296c732.
    1. Yamashita S, Sheth RA, Niekamp AS, et al. Comprehensive complication index predicts cancer-specific survival after resection of colorectal metastases independent of RAS mutational status. Ann Surg. 2017;266:1045–1054. doi: 10.1097/SLA.0000000000002018.
    1. Rössler F, Sapisochin G, Song G, et al. Defining benchmarks for major liver surgery: a multicentre analysis of 5202 living liver donors. Ann Surg. 2016;264:492–500. doi: 10.1097/SLA.0000000000001849.
    1. Kalisvaart M, de Haan JE, Polak WG, et al. Comparison of postoperative outcomes between donation after circulatory death and donation after brain death liver transplantation using the comprehensive complication index. Ann Surg. 2017;266:772–778. doi: 10.1097/SLA.0000000000002419.
    1. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213. doi: 10.1097/.
    1. Sainani KL. Multivariate regression: the pitfalls of automated variable selection. PM R. 2013;5:791–794. doi: 10.1016/j.pmrj.2013.07.007.
    1. Freeman RB, Jr, Wiesner RH, Harper A, UNOS/OPTN Liver Disease Severity Score, UNOS/OPTN Liver and Intestine, and UNOS/OPTN Pediatric Transplantation Committees et al. The new liver allocation system: moving toward evidence-based transplantation policy. Liver Transplant. 2002;8:851–858. doi: 10.1053/jlts.2002.35927.
    1. Duan BW, Lu SC, Wu JS, et al. Model for end-stage liver disease (MELD) score does not predict outcomes of hepatitis B-induced acute-on-chronic liver failure in transplant recipients. Transplant Proc. 2014;46:3502–3506. doi: 10.1016/j.transproceed.2014.07.075.
    1. Yadav SK, Saraf N, Saigal S, et al. High MELD score does not adversely affect outcome of living donor liver transplantation: experience in 1000 recipients. Clin Transplant. 2017;31:e13006. doi: 10.1111/ctr.13006.
    1. Weismüller TJ, Fikatas P, Schmidt J, et al. Multicentric evaluation of model for end-stage liver disease-based allocation and survival after liver transplantation in Germany—limitations of the ‘sickest first’-concept. Transplant Int. 2011;24:91–99. doi: 10.1111/j.1432-2277.2010.01161.x.
    1. Rana A, Hardy MA, Halazun KJ, et al. Survival outcomes following liver transplantation (SOFT) score: a novel method to predict patient survival following liver transplantation. Am J Transplant. 2008;8:2537–2546. doi: 10.1111/j.1600-6143.2008.02400.x.
    1. Montano-Loza AJ, Duarte-Rojo A, Meza-Junco J, et al. Inclusion of sarcopenia within MELD (MELD-Sarcopenia) and the prediction of mortality in patients with cirrhosis. Clin Transl Gastroenterol. 2015;6:e102. doi: 10.1038/ctg.2015.31.
    1. Avolio AW, Cillo U, Salizzoni M, Donor-to-Recipient Italian Liver Transplant (D2R-ILTx) Study Group et al. Balancing donor and recipient risk factors in liver transplantation: the value of D-MELD with particular reference to HCV recipients. Am J Transplant. 2011;11:2724–2736. doi: 10.1111/j.1600-6143.2011.03732.x.
    1. Ma Y, Wang Q, Yang J, et al. Comparison of different scoring systems based on both donor and recipient characteristics for predicting outcome after living donor liver transplantation. PLoS ONE. 2015;10:e0136604. doi: 10.1371/journal.pone.0136604.
    1. de Campos Junior ID, Stucchi RS, Udo EY, et al. Application of the BAR score as a predictor of short- and long-term survival in liver transplantation patients. Hepatol Int. 2015;9:113–119. doi: 10.1007/s12072-014-9563-3.
    1. Pareja E, Cortes M, Hervás D, et al. A score model for the continuous grading of early allograft dysfunction severity. Liver Transplant. 2015;21:38–46. doi: 10.1002/lt.23990.
    1. Muller X, Marcon F, Sapisochin G, et al. Defining benchmarks in liver transplantation: a multicentre outcome analysis determining best achievable results. Ann Surg. 2018;267:419–425. doi: 10.1097/SLA.0000000000002477.
    1. Shimizu S, Saito H, Kono Y, et al. The prognostic significance of the comprehensive complication index in patients with gastric cancer. Surg Today. 2019;49:913–920. doi: 10.1007/s00595-019-01828-3.
    1. Tu RH, Lin JX, Li P, et al. Comprehensive complication index predicts cancer-specific survival of patients with postoperative complications after curative resection of gastric cancer. Gastroenterol Res Pract. 2018;2018:4396018.
    1. Artiles-Armas M, Roque-Castellano C, Conde-Martel A, Marchena-Gómez J. The comprehensive complication index is related to frailty in elderly surgical patients. J Surg Res. 2019;244:218–224. doi: 10.1016/j.jss.2019.06.011.
    1. Ray S, Mehta NN, Mangla V, et al. A comparison between the comprehensive complication index and the Clavien-Dindo grading as a measure of postoperative outcome in patients undergoing gastrointestinal surgery—a prospective study. J Surg Res. 2019;244:417–424. doi: 10.1016/j.jss.2019.06.093.
    1. Goel A, Mehta N, Guy J, et al. Hepatic artery and biliary complications in liver transplant recipients undergoing pretransplant transarterial chemoembolization. Liver Transplant. 2014;20:1221–1228. doi: 10.1002/lt.23945.
    1. Sneiders D, Houwen T, Pengel LHM, et al. Systematic review and meta-analysis of posttransplant hepatic artery and biliary complications in patients treated with transarterial chemoembolization before liver transplantation. Transplantation. 2018;102:88–96. doi: 10.1097/TP.0000000000001936.
    1. Yoo S, Jang EJ, Yi NJ, et al. Effect of institutional case volume on in-hospital mortality after living donor liver transplantation: analysis of 7073 cases between 2007 and 2016 in Korea. Transplantation. 2019;103:952–958. doi: 10.1097/TP.0000000000002394.
    1. Ozhathil DK, Li YF, Smith JK, et al. Impact of center volume on outcomes of increased-risk liver transplants. Liver Transplant. 2011;17:1191–1199. doi: 10.1002/lt.22343.

Source: PubMed

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