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Low Postoperative Platelet Counts Are Associated with Major Morbidity and Inferior Survival in Adult Recipients of Orthotopic Liver Transplantation

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Platelets (PLT) play an essential functional role in cellular injury and liver regeneration following partial hepatectomy and orthotopic liver transplantation (OLT). Here, we investigated the association of postoperative PLT counts with short- and long-term outcomes in adult OLT recipients.

Methods

Three hundred consecutive patients from our prospective OLT database were analyzed retrospectively (May 2010–November 2017). Ninety-day post-OLT complications were graded using the Clavien-Dindo (CD) classification and quantified by the comprehensive complication index (CCI). To determine the prognostic accuracy of PLT counts, the area under the receiver operating characteristic curve (AUROC) was calculated for major complications (CD ≥ 3b). Parametric and non-parametric tests were applied for subgroup analyses. Uni- and multivariable logistic regression analyses were performed to identify risk factors for major complications. Graft and patient survival were analyzed using the Kaplan-Meier method as well as uni- and multivariable Cox regression analyses.

Results

Postoperative day 6 PLT counts < 70 × 109/L (POD6-70) were identified as the best cutoff for predicting major complications (AUROC = 0.7; p < 0.001; Youden index 0.317). The stratification of patients into low- (n = 113) and high-PLT (n = 187) groups highlighted significant differences in major complications (CCI 68 ± 29 vs. 43 ± 28, p < 0.001); length of hospital and intensive care unit (ICU) stay (53 ± 43 vs. 31 ± 25, p < 0.001; 21 ± 29 vs. 7 ± 11, p < 0.001, respectively) and estimated procedural costs. POD6-70 was associated with inferior 5-year graft survival. Multivariable logistic regression analysis identified POD6-70 as an independent predictor of major complications (odds ratio 2.298, confidence intervals 1.179–4.478, p = 0.015).

Conclusion

In OLT patients, a PLT count on POD6 of less than 70 × 109/L bears a prognostic significance warranting further investigations.

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Abbreviations

AIH:

Autoimmune hepatitis

ALF:

Acute liver failure

ALT:

Alanine aminotransferase

ASA:

American society of anesthesiologists

AST:

Aspartate aminotransferase

AUC:

Area under the curve

AUROC:

Area under the receiver operating characteristic curve

BAR:

Balance of risk

BMI:

Body mass index

CCI:

Comprehensive complication index

CD:

Clavien-Dindo

CI:

Confidence interval

CIT:

Cold ischemic time

CP:

Child-Pugh

CVA:

Cerebrovascular accident

DRI:

Donor risk index

ECD:

Extended criteria donor

EAD:

Early allograft dysfunction

FFP:

Fresh frozen plasma

FLR:

Future liver remnant

GGT:

Gamma glutamyltransferase

HCC:

Hepatocellular carcinoma

HPC:

High platelet counts

HR:

Hazard ratio

ICU:

Intensive care unit

INR:

International normalized ratio

LOS:

Length of stay

LPC:

Low platelet counts

MELD:

Model of end-stage liver disease

OLT:

Orthotopic liver transplantation

OR:

Odds ratio

OS:

Overall survival

PBC:

Primary biliary cirrhosis

PLT:

Platelet(s)

POD:

Postoperative day

PSC:

Primary sclerosing cholangitis

RBC:

Red blood cells

RF:

Renal failure

ROC:

Receiver operating characteristic

RRT:

Renal replacement therapy

SE:

Standard error

SOFT:

Survival outcomes following liver transplantation

TPO:

Thrombopoietin

T€:

Thousands of Euros

UH-RWTH:

University Hospital RWTH

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Authorship

The study was designed by the initiating study team (ZC, GL, IA, and UPN). Data collection and analysis were performed by ZC, IA, GL, JB, JoB, DAMS, FAM, WJL, JvdM, and UPN. Initial manuscript was drafted by ZC, IA, and GL. Furthermore, DAMS, JB, JoB, DAMS, FAM, UPN, WJL, PS, and JvdM have substantially contributed to the final version of the manuscript. All authors have read and approved the final version of the manuscript.

Funding

This research project was supported by the START-Program (#136/17 to GL and #23/19 to ZC) of the Faculty of Medicine, RWTH Aachen and by the Excellence Initiative of the German federal and state governments (G:(DE-82) ZUK2-SF-OPSF443 to GL). The funders were not involved in study design, data collection, data analysis, manuscript preparation, or decision to publish.

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Author notes

  1. Iakovos Amygdalos and Zoltan Czigany contributed equally to this work.

Authors and Affiliations

  1. Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany

    Iakovos Amygdalos, Zoltan Czigany, Jan Bednarsch, Joerg Boecker, Daniel Antonio Morales Santana, Franziska Alexandra Meister, Jelena von der Massen, Wen-Jia Liu, Ulf Peter Neumann & Georg Lurje

  2. Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany

    Pavel Strnad

  3. Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands

    Ulf Peter Neumann

Authors
  1. Iakovos Amygdalos
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  2. Zoltan Czigany
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  3. Jan Bednarsch
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  4. Joerg Boecker
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  5. Daniel Antonio Morales Santana
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  6. Franziska Alexandra Meister
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  7. Jelena von der Massen
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  8. Wen-Jia Liu
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  9. Pavel Strnad
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  10. Ulf Peter Neumann
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  11. Georg Lurje
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Corresponding author

Correspondence to Georg Lurje.

Ethics declarations

The study was conducted at the UH-RWTH in accordance with the requirements of the Institutional Review Board of the RWTH Aachen University (EK-047/18), the current version of the Declaration of Helsinki as well as the Declaration of Istanbul, and the good clinical practice guidelines (ICH-GCP). Informed consent was waived due to the retrospective study design and collection of readily available clinical data.

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Amygdalos, I., Czigany, Z., Bednarsch, J. et al. Low Postoperative Platelet Counts Are Associated with Major Morbidity and Inferior Survival in Adult Recipients of Orthotopic Liver Transplantation. J Gastrointest Surg 24, 1996–2007 (2020). https://doi.org/10.1007/s11605-019-04337-3

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