Catalan Liver Transplant Registry by rub18840

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									Catalan
Liver
Transplant
Registry


Statistical Report 1984-2007
Catalan Liver Transplant Registry. 1984-2007




Catalan Liver Transplant Registry Advisory Committee

Dr. Joan Fabregat (Hospital Universitari de Bellvitge)
Dr. Juan Carlos García-Valdecasas (Hospital Clínic i Provincial de Barcelona)
Dra. Itxarone Bilbao (Hospital Universitari General de la Vall d’Hebron)
Sra. Nuria Trota (Organització Catalana de Trasplantaments. Servei Català de la Salut)
Dra. Rosa Deulofeu (Organització Catalana de Trasplantaments. Servei Català de la Salut)


Notifying centers

Hospital Universitari de Bellvitge
Hospital Clínic i Provincial de Barcelona
Hospital Universitari General de la Vall d’Hebron
Hospital Universitari Maternoinfantil de la Vall d’Hebron


Person in charge of registry: R. Deulofeu, director of OCATT
Registry management: Catalan Liver Transplant Registry Advisory Committee
Registry technician: N. Trota


Data collection: N. Trota
Data analysis and written report: N. Trota




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                                                Catalan Liver Transplant Registry. 1984-2007



Acknowledgments
The Catalan Transplant Organization (OCATT), which is responsible for the Catalan
Liver Transplant Registry, would like to thank all the members of the liver transplant
teams of the different hospitals for their contribution to maintaining the registry by
collecting and transmitting data and for their participation in the preparation of this
report.



Dr. Rosa Deulofeu
Director of OCATT




Correspondence to:

Ms. Nuria Trota
Organització Catalana de Trasplantaments (OCATT)
Servei Català de la Salut. Departament de Salut
Mejía Lequerica 1, pavelló Hèlios 3, 1a planta
08028 Barcelona

E-mail: ntrota@catsalut.cat

http://www.gencat.ocatt.cat



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Catalan Liver Transplant Registry. 1984-2007




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                                                                       Catalan Liver Transplant Registry. 1984-2007



Contents
Introduction ............................................................................................................... 7

Methodological aspects and definitions ..................................................................... 8

Evolution of liver transplants...................................................................................... 9

Liver transplants in adults........................................................................................ 13

      Recipient characteristics................................................................................... 13

      Donor characteristics........................................................................................ 21

      Transplant Characteristics ................................................................................ 25

      Retransplants ................................................................................................... 32

      Survival ............................................................................................................ 34

      Mortality............................................................................................................ 46

      Waiting List....................................................................................................... 49

Liver Transplants in Children................................................................................... 51

      Recipient characteristics................................................................................... 51

      Donor characteristics........................................................................................ 53

      Transplant Characteristics ................................................................................ 54

      Retransplants ................................................................................................... 54

      Survival ............................................................................................................ 55

      Mortality............................................................................................................ 57

      Waiting List....................................................................................................... 57




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Catalan Liver Transplant Registry. 1984-2007




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                                                 Catalan Liver Transplant Registry. 1984-2007




Introduction
In 1984, , the first liver transplant carried out in Catalonia was performed at Hospital
Universitari de Bellvitge. In 1985, Vall d’Hebron Children’s Hospital began work in
this field and, in 1988, Vall d’Hebron General Hospital and Hospital Clinic were given
authorization.

The Catalan Liver Transplant Registry (RTHC) went into operation in 1994 and
contains the information on transplants performed in Catalonia since 1984. The data
on the transplants performed between 1984 and 1993 were collected retrospectively.
The registry has been collecting data periodically and systematically since 1994.

In accordance with its objectives, the registry provides the information requested by
the Catalan Health Service and the Department of Health of the Catalan Autonomous
Government for planning and managing resources and the purchase of health
services. The registry is also a source of information that is available to healthcare
professionals and also answers requests for information from other areas. In all
cases, release of RTHC data is subject to existing legislation on the processing and
usage of personal data.

The information provided herein attests to the practical results that can be obtained
when health professionals and the Administration collaborate in the development and
consolidation of the instruments that make health policies and services effective.

The main aim of this document is to provide information on the activity,
characteristics and results of the liver transplants performed in Catalonia from 1984
to 2007 to both professionals directly involved in this treatment and to the health
authorities.




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Catalan Liver Transplant Registry. 1984-2007




Methodological aspects and definitions
The report is divided into three sections: the first provides a brief, descriptive analysis
of the evolution of liver transplants in Catalonia using global data from the registry;
whereas the second and third sections discuss more specific data by age of
recipient—adults (patients of 15 years of age and over) and children (patients under
the age of 15 years).

The second and third sections analyze the characteristics of the recipients, the
donors, the transplants, and the results obtained. Recipient characteristics include
patient data at the time of the first transplant, thus excluding patients who received
their first transplant outside Catalonia (also excluded are adults who received their
first transplant as pediatric patients) and who underwent retransplant in Catalonia.

Indications and causes of failure and death use the same classification system as in
previous reports. The 2002-2003 report, available at the OCATT website, provides a
detailed description of the disease and failure codes included in each category.

Patient survival (time until death) and graft survival (time until transplanted organ fails
or patient dies) were calculated using the actuarial method and the level of statistical
significance between the different curves was evaluated using the Wilcoxon (Gehan)
test. Survival curves were interrupted when the number of cases was less than 10
and patients who had previously or subsequently received a transplant in another
hospital were excluded.

The probability of receiving a transplant was calculated using a model of competing
risks between three events of interest: transplant, death and removal from the list.


Description of indicators:

Annual liver transplant rate in Catalonia
Total number of transplants performed in a year in authorized hospitals,
independently of place of residence of recipient and origin of donor with respect to
the population of Catalonia (population census of 1991 and 1996, and annual census
updates from 1997 onward Instituto Nacional de Estadística). Figures per million
population (pmp).




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                                                                                             Catalan Liver Transplant Registry. 1984-2007




Evolution of liver transplants
A total of 3453 liver transplants were performed on 3135 patients (321 retransplants)
in Catalonia between 1984 and 2007. The annual evolution of the number of liver
transplants shows a rising trend (Figure 1), although there have been some
oscillations in recent years. 212 transplants (on 206 patients) were performed in
2007.

Figure 1. Annual evolution of number of transplants and rate of liver transplants. 1984-2007

        Number of transplants                                                                                                  Transplant rate (pmp)

  350                                                                                                                        34,3
                                                                                                                                           32,5
                                                                                                  30,7 31,4 30,3 31,4 31,4
                                                                                                                                    29,6                 29,4
  300                                                                   28,1 28,7          28,7                                                   28,6          30
                                                                                    26,9
                                                                 25,1
  250                                              23,1                                                                      230           227
                                                          22,1                                                                                           212
                                                                                                                 200 204            202           204
  200
                                            19,6                                                  189 195 190                                                   20
                                                                        170 174 164 175
                                                                 152
  150                                13,5          140 134
                                            117

  100                                81                                                                                                                         10
                               5,9
   50              4            35
         2,2       24   2,7
         13 0,8         16
             5
    0                                                                                                                                                           0
         84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07
                                                                        Year of transplant
                              First transplants (n = 3.132)               Retransplants (n = 321)            Transplant rate (pmp)

        Number of transplants = 3.453




The same trend can be seen in the annual liver transplant rate (Figure 1), which was
29.4 transplants per million population (pmp) in 2007. The annual transplant rate
varies considerably between regions and countries, with Catalonia presenting some
of the highest levels of activity (Figure 2).

This data should be interpreted taking into account the different factors that affect
transplant activity in each country, such as the health-care system, indication criteria,
population structure, and cultural aspects.

Of the patients who received transplants, 84.6% (n=2653) were resident in Catalonia,
14.3% (n=448) resided in the rest of Spain, and 0.7% (n=21) were foreigners. This
information was not available for 12 patients. The majority of residents in Catalonia
belonged to the Barcelona health-care region, followed by the Catalunya Central
health-care region.




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Catalan Liver Transplant Registry. 1984-2007



Figure 2. Liver transplant rates in different countries. 2007

         Catalonia                                                                                                              29,4


               Spain                                                                                          24,6

         Germany                                                    14

           Austria                                                   14,3

          Belgium                                                                                                  25,2

           France                                                                 16,8

      Netherlands                                    9,1

                Italy                                                                    18,4

          Portugal                                                                                                 25,1

                 UK                                        10,7


          Canada                                                       14,6

               USA                                                                                    21,4

                         0              5            10              15                    20                25             30               35

                                                                   Transplant rate (pmp)

     Source: Newsletter Transplant. International Figures on Organ Donation and Transplantation - 2007. Septiembre 2008. Vol. 13,
     No. 1.



Of the 3453 transplants carried out in Catalonia throughout the entire period, 3241
were in patients of 15 years and over (2960) and 212 transplants were in children
under 15 years of age (179). In 2007, 204 transplants were performed on adults and
eight on children.

Figure 3. Number of patients who received a liver transplant, grouped by age and sex. 1984-
2007

                 Age group (years)
       70-74
       65-69
       60-64
       55-59
       50-54
       45-49
       40-44
       35-39
       30-34
       25-29
       20-24
       15-19
       10-14
         5-9
         0-4
                        400       300          200           100              0                 100          200          300          400
                                                     Men (n = 2.034)          Women (n = 1.098)

                  Number of patients (first transplants) = 3.132




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                                                                       Catalan Liver Transplant Registry. 1984-2007



The mean age of patients who received a first liver transplant was 49.6 years of age
and the median was 54 years of age (SD=15.4, range=0-73). The 55-59 years of age
range accounts for the highest number of cases (Figure 3), representing 20% of all
patients. In 2007, patients over the age of 60 years represented 28.5% of patients—
an increase in the figure of 11.6% in 1992. In overall terms, they represent 24.1% of
patients receiving a first transplant.

There are differences in the distribution of indications in Catalonia, Spain and Europe
and these differences may be due, in part, to the different criteria used when
including patients on the waiting list and, in part, to differences in the way the data
was processed (Figure 4). For example, in the European registry (ELTR), the
cancers category includes hepatocellular carcinoma and other liver malignancies,
whereas the Spanish liver-transplant registry (RETH) and the Catalan registry
(RTHC) only includes hepatocellular carcinoma with or without cirrhosis.

Figure 4. Main diagnosis of first liver transplant in patients of all ages. Comparative data from
                                1                                     2
the European registry (ELTR) , the Spanish registry (RETH) , and the Catalan registry
(RTCH). 1984-2007

           Percentage of patients (first transplants)
    100%


     80%


     60%


     40%


     20%


      0%
                           RTHC                                 RETH                               ELTR
                        (1984-2007)                          (1984-2007)                        (1988-2007)
                         (n = 3.132)                         (n = 13.501)                       (n = 57.956)

                                  Acute hepatic failure *     Cholestatic diseases *   Cirrhosis *
                                  Hepatocellular carcinoma    Metabolic diseases *     Others *

                                                                                       * without hepatocellular carcinoma




The most common indicated disease for liver transplant in Catalonia was cirrhosis
(51.7%), followed by hepatocellular carcinoma (27.2%), although there were
differences depending on the age of the receiver (Figure 5). In patients under the age
of 15 years, the most frequently indicated disease was congenital biliary disease,
grouped within the “others” category.

Given the differences between the characteristics of transplants performed in adults
and those performed in children, both from the perspective of indications and from
the perspective of the transplant and its evolution, the results for each of these
populations were analyzed separately.
1
  European Liver Transplant Registry 01/1988-06/2007 (available at: http://www.eltr.org).
2
  Registro Español de Trasplante Hepático. Novena memoria de resultados. 1984-2007
(available at: http://www.ont.es).


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Catalan Liver Transplant Registry. 1984-2007



Figure 5. Percentage of patients who received a liver transplant, by primary diseases and
age group. 1984-2007


                       Adults (>= 15 years)                                          Children (< 15 years)
                             (n = 2.953)                                                      (n = 179)



         54,5%
                                                                     60,3%
                                                        6,0%


                                                            5,0%
                                                                                                                         17,9%
                                                            2,6%
                                                            3,1%

                                                                                                                       0,6%
                                                                                                                    5,6%
                                                                                                               3,4%
                                       28,8%                                                     12,3%


                                    Acute hepatic failure *        Cholestatic diseases *       Cirrhosis *
                                    Hepatocellular carcinoma       Metabolic diseases *         Others *

        Number of transplants (first transplants) = 3.132                                   * without hepatocellular carcinoma




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                                                                                  Catalan Liver Transplant Registry. 1984-2007




Liver transplants in adults
Of the 3453 transplants performed in Catalonia between 1984 and 2007, 3241 were
in patients of 15 years of age or older (2953 first transplants and 288 retransplants).
These transplants were carried out on 2960 patients, as three of the patients
received the first transplant outside Catalonia and four patients receive the transplant
as children (Figure 6).

204 transplants were performed in 2007; 194 of which were first transplants and 10
retransplants.

Figure 6. Evolution of number of liver transplants, patients aged 15 years or over. 1984-2007

        Number of transplants
  240
                                                                                                                    221         217
  220                                                                                                                                       204
                                                                                                        195               195         194
  200                                                                                   185 185
                                                                                                              190
                                                                                                  177
  180                                                                 170         172
                                                                156         155
  160
                                                          139
  140                                           124 127
  120                                     107
  100
   80
                                     63
   60
   40                           30

   20     12        12   9
               2
   0
          84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07
                                                                Year of transplant
                                            First transplants (n = 2.953)         Retransplants (n = 288)

        Number of transplants = 3.241




Recipient characteristics

   ♦ Gender and age

Of the 2953 patients who received a first transplant in Catalonia in the 1984-2007
period, 1940 (65.7%) were men and 1013 (34.3%) were women. The proportion of
women gradually decreased over these years and went from 43.8% in 1984-1991
period to 29.9% 2003-2007 period. In 2007, the proportion of women was 30.9%.

The mean age of the patients who received their first liver transplant in the 1984-
2007 period was 53, the median age was 55 and the range was from age 15 to 73.
The mean age went from 49.1 years in 1992 (range=17-65, 95% CI=47.0-51.3) to
53.8 years in 2007 (range=16-69, 95% CI=52.4-55.3) (Figure 7). There was a
progressive increase in the mean age, which stabilized at approximately 53-54 years
in 1999.



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Catalan Liver Transplant Registry. 1984-2007



Figure 7. Evolution of age of patients who received a first liver transplant, patients aged 15
years or over. 1992-2007


            Number of patients (first transplants)                                                            Mean age (years)
      250                                                                                                                        60


                                                                                                                                 50
      200

                                                                                                                                 40
      150

                                                                                                                                 30

      100
                                                                                                                                 20

       50
                                                                                                                                 10


        0                                                                                                                        0
              92     93     94      95     96        97   98       99     00        01      02    03   04    05    06    07
                                                               Year of transplant
                               Mean age         15-30 years        31-50 years           51-60 years   >60 years
                                                 (n = 123)         (n = 773)              (n = 998)    (n = 742)




     ♦ Indications

Indications for transplant were grouped into six categories: acute hepatic failure
(AHF), cholestatic diseases, cirrhosis, hepatocellular carcinoma, metabolic diseases,
and others, according to the code recorded in the main diagnosis.

In the 1984-2007 period, almost three quarters of transplanted patients (with a first
transplant) belonged to only two of these six groups: 54.5% presented cirrhosis and
28.8% presented hepatocellular carcinoma (Figure 8). These percentages were
53.6% and 32.0%, respectively, in the first transplants performed in 2007.

Hepatocellular carcinoma is the indicator that has grown most over the years and is
currently at twice the percentage shown in 1992, although this has not always been a
rising one over these years; in 2001, hepatocellular carcinoma represented 45.3% of
all indications, from which time it began to decrease and in recent years, the
percentage has stabilized at approximately 30%. Other indications remained
relatively stable (Figure 9).

Cirrhosis constitutes the most frequent group of transplant-indicated diseases in all
groups of patients over the age of 30 years, although as age increases, the
proportion of transplants where the indication is hepatocellular carcinoma also
increases and this disease represents 46.8% of all diagnoses in patients over 60
years of age (Figure 10).




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                                                                                Catalan Liver Transplant Registry. 1984-2007



Figure 8. Main diagnosis for first liver transplant, patients aged 15 years or over. 1984-2007




                                 Cirrhosis *
                                   54,5%
                                                                                               Cholestatic diseases *
                                                                                                       6,0%


                                                                                                    Acute hepatic failure*
                                                                                                           5,0%
                                                                                                    Others *
                                                                                                     2,6%
                                                                                                    Metabolic diseases *
                                                                                                           3,1%




                                                                      Hepato. carcinoma
                                                                           28,8%

          Number of patients (first transplants) = 2.953                                       * without hepatocellular carcinoma




Figure 9. Evolution of main diagnosis for first liver transplant, patients aged 15 years or over.
1992-2007

           Number of patients (first transplants)
    220
    200
    180
    160
    140
    120
    100
     80
     60
     40
     20
      0
             92      93     94      95         96   97     98       99     00        01   02   03      04     05      06     07
                                                                Year of transplant
                                     Acute hepatic failure *          Cholestatic diseases *    Cirrhosis *
                                     Hepatocellular carcinoma         Metabolic diseases *      Others *

                                                                                               * without hepatocellular carcinoma




Diagnoses of cholestatic diseases and acute hepatic failure are more common in
women than in men. Hepatocellular carcinoma, on the other hand, is more common
in men, although differences tend to decrease in the latter periods (Figure 11).




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Catalan Liver Transplant Registry. 1984-2007



Figure 10. Main diagnosis for first liver transplant by age group, patients aged 15 years or
over. 1992-2007

               Percentage of patients (first transplants)
     100%


      80%


      60%


      40%


      20%


       0%
                       15-30 years                   31-50 years                51-60 years                    >60 years
                         (n = 156)                     (n = 916)                 (n = 1.125)                    (n = 756)
                                                                   Age group
                                        Acute hepatic failure *      Cholestatic diseases *      Cirrhosis *
                                        Hepatocellular carcinoma     Metabolic diseases *        Others *

            Number of patients (first transplants) = 2.953                                     * without hepatocellular carcinoma




Figure 11. Main diagnosis for first liver transplant by period and sex of recipient, patients
aged 15 years or over. 1992-2007

              Percentage of patients (first transplants)
     100%


     80%


     60%


     40%


     20%


      0%
                 Men    Women                     Men    Women                  Men    Women                    Men    Women
                   1984-1991                        1992-1996                     1997-2002                       2003-2007
                                                               Year of transplant
                                        Acute hepatic failure *      Cholestatic diseases *      Cirrhosis *
                                        Hepatocellular carcinoma     Metabolic diseases *        Others *

            Number of patients (first transplants) = 2.953                                     * without hepatocellular carcinoma


Cirrhosis
Cirrhosis is the most frequent indication, with 1610 patients, 54.5% of the. Alcoholic
cirrhosis and virus C related cirrhosis are the most common (Figure 12).



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                                                                                Catalan Liver Transplant Registry. 1984-2007



In the last three years, there has been an decrease in the frequency of alcoholic
cirrhosis and an increase in virus C related cirrhosis (Figure 13).

Figure 12. Main diagnosis of cirrhosis in first transplant, patients aged 15 years or over.
1984-2007


                                                                                       Alcoholic
                                                                                        35,2%

                    Alcoholic + virus C
                          7,9%




                                                                                                          Others and related
                                                                                                                 7,5%



                                                                                                    Unknown causes
                                 Virus C                                                                 5,8%
                                 37,6%
                                                                                          Virus B
                                                                                           6,0%

      Number of patients (first transplants) with cirrhosis as main diagnosis = 1.610




Figure 13. Evolution of main diagnosis of cirrhosis in first liver transplant, patients aged 15
years or over. 1992-2007

          Number of patients (first transplants)
    110
    100
     90
     80
     70
     60
     50
     40
     30
     20
     10
      0
            92      93     94      95      96      97      98       99     00        01     02      03     04     05     06    07
                                                                Year of transplant

                                     Alcoholica         Alcoholica + virus C         Virus C
                                     Virus B            Unknown causes               Others and related




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Catalan Liver Transplant Registry. 1984-2007



Hepatocellular carcinoma
Hepatocellular carcinoma represents 28.8% (850) of patients transplanted in the
1984-2007 period and is the second most frequent indication. Some 96.8% of these
cases are accompanied by cirrhosis or another liver disease —virus C related
cirrhosis in most cases (Figures 14 and 15).

Figure 14. Main diagnosis of hepatocellular carcinoma in first liver transplant, patients aged
15 years or over. 1984-2007


                                                                                   HCC + virus B cir.
                                                                                        4,9%


                                                                                                    HCC + alcoholic cir.
                                                                                                         16,1%




                                                                                                        HCC without cirrhosis
                                                                                                               3,2%
                 HCC + virus C cir.
                     66,8%

                                                                                                    HCC + other diseases
                                                                                                           8,9%




      Number of patients (first transplants) with hepatocellular carcinoma (HCC) as main diagnosis = 850


Figure 15. Evolution of main diagnosis of hepatocellular carcinoma in first liver transplant,
patients aged 15 years or over. 1992-2007

          Number of patients (first transplants)
     90

     80

     70

     60

     50

     40

     30

     20

     10

      0
            92      93     94      95      96      97    98       99     00        01     02       03     04        05     06   07
                                                              Year of transplant
                                  HCC + alcoholic cir.         HCC + virus B cir.              HCC + virus C cir.
                                  HCC + other diseases         HCC without cirrhosis




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                                                Catalan Liver Transplant Registry. 1984-2007



Acute hepatic failure
Acute hepatic failure represents 5.0% (149) of patients transplanted in the 1984-2007
period. In most cases (91.3%, 136 patients), the cause was fulminant or subfulminant
hepatitis of viral or unknown origin.


Cholestatic disease
Cholestatic disease forms one of the least common diagnostic groups with 177
(6.0%) cases for the same period. Primary biliary cirrhosis represents 66.7% of all
cases and sclerosing cholangitis, 28.2%.


Metabolic disease
Of the patients who received a transplant in this period, 91 (3.1%) had a metabolic
disease. In most cases (70.3%, 64 patients), the disease was familial amyloidotic
polyneuropathy.


Others
These comprise the least frequent group, with 76 patients (2.6%) in the 1984-2007
period.

Other causes for transplant include 31 patients who presented a malignant tumor, 13
with congenital liver disease, 14 with Budd-Chiari disease, 10 with a benign tumor or
polycystic liver disease, and 8 with another type of liver disease.


   ♦ Infection by hepatitis B and C viruses

The proportion of HBsAg positive patients in the 1984-2007 period is 8.1% and this
figure has remained relatively stable over recent years, although there is a slight
downward trend (Figure 16).

Of the patients who received a transplant in the 1984-2007 period, 49.9% tested
positive for the hepatitis C virus.


   ♦ HIV infection

In 2002, the four first liver transplants were performed in patients infected with the
HIV virus. Since then, the total number of transplants performed due to this indication
is 37 (35 patients).

The indication for 65.7% (23) of these patients was cirrhosis, principally due to
hepatitis C and 28.6% (10) was hepatocellular carcinoma.




                                                                                         19
Catalan Liver Transplant Registry. 1984-2007



Figure 16. Evolution of annual percentage of patients aged 15 years or over who tested
positive for HBV and HCV. 1992-2007


          Percentage of positive pacients
     70

                                                        58,6
     60                             55,2         55,1                               54,2
                      52,4                 53                     53,2                            53
                                                                                           49,7          50,8   50,7    49,7
     50        47,8                                                       47,2                                                 46,1
                             42,3
     40

     30

     20
                             10,9                                                                        12,2
                                           9,8                                      8,9                          9,4
     10        7,8                  7,8          7,7                                       6,7                           7,1 7,5
                      6,3                               4,9               6,2                     6,1
                                                                  2,9

      0
          92          93     94     95     96    97     98        99      00        01     02     03      04     05      06           07
                                                               Year of transplant
                                                               HBsAg      Anti VHC

                                                                                            Missing data = 10 (HBsAg) / 5 (Anti VHC)




20
                                                                              Catalan Liver Transplant Registry. 1984-2007




Donor characteristics

   ♦ Gender and age

The mean age of liver donors was 46 years in the 1992-2007 period and this
figure has increased progressively over the years, from 32 years (95% CI=30-35.5,
maximum age=65 years) in 1992 to 52 years (95% CI=49.6-54.6, maximum age=83
years) in 2007 (Figure 17).
This increase occurs due to the oldest patients, as in 2007, 20.1% were 70 years of
age or older, whereas this group did not exist in 1992. Furthermore, donors below the
age of 40 years represented 65.4% of cases but had fallen to 25.0% in 2007.

Figure 17. Evolution of donor age in transplants in patients aged 15 years or over. 1992-2007


          Number of donors                                                                                Mean age (years)
    270

    240                                                                                                                      50

    210
                                                                                                                             40
    180

    150                                                                                                                      30

    120
                                                                                                                             20
     90

     60
                                                                                                                             10
     30

      0                                                                                                                      0
           92     93    94      95      96       97     98       99     00        01   02     03    04    05    06     07
                                                             Year of transplant
                   Mean age          <40 years        40-49 years        50-59 years        60-69 years    >70 years

      Number of donors = 2882




In the 1992-2007 period, 64.3% of donors were men and 35.7% were women; these
percentages have remained stable over the years.

The mean age of male donors in the 1992-2007 period is 44 years (SD= ±18.6, 95%
CI=43.7-45.5, maximum age=87 years) and the mean age of female donors is 48
years (SD=±18.1, 95% CI=47.2-49.4, maximum age=84 years).


   ♦ Type

95.2% of all transplants in 1992-2007 period were performed using organs from
brain-death cadaveric donors (taken into account the 1984-2007 period was 95.7%).




                                                                                                                                  21
Catalan Liver Transplant Registry. 1984-2007



Since the first domino transplants in 1999, the first living donor transplants in 2000
and the first non-heart-beating donor in 2002, these types of donor have gradually
increased, although there have been some fluctuations (Figure 18).

Figure 18. Evolution of number of living, domino and non-heart-beating donor transplants in
patients aged 15 years or over. 1999-2007

           Number of donors
      16

      14
                                                 13

      12
                                    10                10
      10
                                         9                     9   9                                                   9

      8
                        7                                                                7                                  7
                                                                                             6        6
      6
                              5                                                                                    5
                                                                            4   4                 4
      4         3                                                                    3                    3
                                                                        2                                      2
      2
                                                           1

      0
               99             00         01           02           03           04           05           06           07
                                                           Year of transplant
                                   Living (n = 61)     Domino (n = 58)      Non-heart-beating (n = 19)




63.8% (37) of domino donors were men and 36.2% (21) were women, with a mean
age of 38 years (95% CI=35.6-41.8, range=22-67).

67.2% (41) of living donors were men and 36.2% (20) were women, with a mean age
of 34 years (95% CI=31.6-36.8, range=19-76).

The donor was a child of the recipient, in 63.9% (39) of living donor transplants, a
parent in 1.6% (1), a sibling in 11.5% (7), a partner in 6.6% (4), and another family
member or a friend in 16.4% (10).

The majority of non-heart-beating donors were men (94,7%), with a mean age of 43
years (95% CI=36.1-50.8, range=20-65).


     ♦ Cause of death

In brain-death cadaveric donors, there has been a parallel increase over the years in
donor age and in the proportion of deaths due to cerebrovascular accident (CVA) or
stroke, and a corresponding parallel reduction in donor age and death due to
traumatic brain damage (TBD). In 1995, for example, 41.8% of all liver donors had
died from TBD and 50.0% from stroke, whereas these figures were 19.1% and
67.8%, respectively, in 2007 (Figure 19).




22
                                                                               Catalan Liver Transplant Registry. 1984-2007



Figure 19. Evolution of cause of death in transplants in patients aged 15 years or over. 1992-
2007

           Percentage of donors
    100%



     80%



     60%



     40%



     20%



      0%
             92     93     94       95     96      97     98       99     00        01   02   03   04       05   06   07
                                                               Year of transplant

                                TBD - traffic accidents    TBD - others         Stroke    Anoxia   Others

      Number of cadaveric donors (brain death) = 2744




In the 1992-2007 period, 64.0% of donors who died due to TBD were men as were
68.1% of those who died from stroke.

During this period, the mean donor age was 31 years (95% CI=30.5-33.3, range=5-
87) in deaths due to TBD following traffic accident, 41 years (95% CI=39.0-43.4,
range=3-85) in deaths due to TBD caused by other incidents and 54 years (95%
CI=53.4-54.8, range=7-86) in deaths due to stroke.

The mean age of donors who died due to TBD was 28 years (25 years due to a traffic
accident and 33 years caused by other incidents) in 1992 and 37 years (33 years due
to a traffic accident and 43 years caused by other incidents) in 2007. The mean age
of donors who died due to stroke was 41 years in 1992 and 59 years in 2007.


   ♦ Origin

If transplants from different periods are compared, there is an increase in the
proportion of organs originating from the transplant hospital and a drop in the organs
from the rest of Spain or from abroad. The proportion of organs from Spain has
increased over the 2003-2007 period in comparison with the previous period, due to
the gradual increase in organs from the Balearic Islands included in this category
(Figure 20).

In the 1984-1991 period, 15.9% of transplanted livers came from the same hospital;
this proportion increased to 36.9% in the last period. The percentage of organs from
other hospitals in Catalonia, however, has remained stable: 43.0% in the 1984-1991
period and 41.3% in the 2003-2007 period.




                                                                                                                           23
Catalan Liver Transplant Registry. 1984-2007



Figure 20. Evolution of donor origin in transplants in patients aged 15 years or over. 1984-
2007

            Percentage of transplants
     100%



      80%



      60%



      40%



      20%



      0%
                    1984-1991               1992-1996                        1997-2002             2003-2007
                                                        Year of transplant
                              Same center   Center of Catalonia       Center of Spain    Foreign center

      Number of transplants = 3.193                                                                  Missing data = 48




In 2007, 38.2% of livers came from the same hospital, 41.7% came from other
hospitals in Catalonia, 18.6% from other hospitals in the rest of Spain and 1.5% from
foreign hospitals.




24
                                                                  Catalan Liver Transplant Registry. 1984-2007




Transplant Characteristics

   ♦ Urgency

Of the 3241 liver transplants performed in adults in the 1984-2007 period, 256 (7.9%)
were urgent. Of these, 60.5% were first transplants, 37.9% were second transplants,
and 1.6% were third and fourth transplants.

In 2007, 15 urgent transplants were performed, 11 of which were first transplants and
4, second transplants.

The number of urgent transplants has fallen over the years in first transplants but has
increased slightly in retransplants (Figure 21).

Figure 21. Evolution of urgent transplants and number of transplants in patients aged 15
years or over. 1984-2007

          Percentage of transplants
   100%



    80%



    60%



    40%



    20%



     0%
            1st tx   Re-tx            1st tx   Re-tx               1st tx   Re-tx        1st tx   Re-tx
              1984-1991                 1992-1996                    1997-2002             2003-2007
                                                   Year of transplant
                                          Elective (n = 2983)    Urgent (n = 256)

      Number of transplants = 3239                                                         Missing data = 2




   ♦ Gender compatibility

In the 1992-2007 period, the proportion of transplants with organs from donors of the
same sex as the recipient was 57.5%; transplants in men with a liver from a woman
represented 22.1% and transplants from a male donor to a female received
represented 20.4%.




                                                                                                              25
Catalan Liver Transplant Registry. 1984-2007



     ♦ Blood group compatibility

In recent years, there has been an increase in identical transplants and a reduction in
compatible and incompatible transplants, particularly in non-urgent transplants
(Figure 22).

Figure 22. Evolution of blood-group compatibility in transplants in patients aged AB0 years or
over. 1984-2007

            Percentage of transplants
     100%



      80%



      60%



      40%



      20%



      0%
             1984-1991 1992-1996 1997-2002 2003-2007                1984-1991 1992-1996 1997-2002 2003-2007
                        All transplants                                              Non-urgent transplants
                                          Isogroup     Compatible     Incompatible
        Number of transplants = 3228                                                              Missing data = 13




     ♦ Type of liver graft

A full size cadaveric donor (brain death and non-heart-beating) organ was used in
95.5% of liver transplants in the registry, whereas a split transplant was performed in
0.6% of cases. Taking into account domino donor transplants and cadaveric donors,
full size grafts increase to 97.2% and split to 0.7%. Living donor transplants represent
1.9%. There has been some variation in both split transplants and living donor
transplants in the last period (Table 1).


     ♦ Technique used in anhepatic phase

The piggy-back technique (with or without portacaval anastomosis) was used in 90%
of transplants performed between 1984 and 2007. The number of transplants using
the classical technique has fallen over the years; this technique was used in the initial
years and is practically obsolete today.




26
                                                                         Catalan Liver Transplant Registry. 1984-2007



Table 1. Evolution of transplant type, transplants in patients aged 15 years or over. 1997-
2007

                      Full size                     Living Donor                                     Split
                                                                                                                              Total
                  n                  %                n                 %                       n               %
 1997           170             100,0                 -                  -                      -                -                170
 1998           182             98,9                  -                  -                      2               1,1               184
 1999           183             98,9                  -                  -                      2               1,1               185
 2000           166             94,3                  7                4,0                      3               1,7               176
 2001           183             94,3                 10                5,2                      1               0,5               194
 2002           175             92,1                 13                6,8                      2               1,1               190
 2003           209             94,6                  9                4,1                      3               1,4               221
 2004           191             97,9                  4                2,1                      0               0,0               195
 2005           206             95,8                  7                3,3                      2               0,9               215
 2006           185             95,8                  6                3,1                      2               1,0               193
 2007           198             97,1                  5                2,5                      1               0,5               204
Total          2.048            96,3                 61                2,9                      18              0,8          2.127


Figure 23. Evolution of type of preservation solution used in transplants in patients aged 15
years or over. 1984-2007

           Percentage of transplants
    100%



     80%



     60%



     40%



     20%



      0%
                    1984-1991                  1992-1996                        1997-2002                    2003-2007
                                                           Year of transplant
                                     Collins   Wisconsin        Bretschneider         Celsior       Others

      Number of transplants = 3234                                                                             Missing data = 7




                                                                                                                                    27
Catalan Liver Transplant Registry. 1984-2007



     ♦ Preservation solution

The Wisconsin University solution is the most commonly used preservation solution
(87.9% of all transplants between 1984 and 2007) (Figure 23), although there has
been an increase in the use of the Celsior solution in more recent years.


     ♦ Ischemia time

The mean cold ischemia time has fallen over the years (Figure 24). For the entire
period, the mean cold ischemia time was 7,02 hours (median=6.5 hours, range=0.5-
20.83 hours). Between 1992 and 2007, cold ischemia time fell significantly (P<.0001)
from a mean time of 8.1 hours (95% CI=7.6-8.6, range=3.2-15.7) to 6.7 hours (95%
CI=6.5-7.0, range=0.8-14.0).

Figure 24. Annual evolution of number of transplants and mean duration of ischemia in
transplants in patients aged 15 years or over. 1992-2007

            Year of transplant
     1992
     1993
     1994
     1995
     1996
     1997
     1998
     1999
     2000
     2001
     2002
     2003
     2004
     2005
     2006
     2007
            0                     2         4                           6          8                    10
                                                Ischemia time (hours)
            Number of transplants = 2.869
                                                                  CI 95%    Mean       Mean 1992-2007
            Missing data = 13




     ♦ Patient status before transplant

Of the patients who received a transplant between 1984 and 2007, 85.2% were at
home with normal function and/or receiving continuous medical care before their
transplant, 6.8% required continuous hospitalization, and 8.0% were in an intensive
care unit.

When only patients who received an elective transplant were included (excluding
urgent transplants), the proportion of patients who were at home with normal function
and/or receiving continuous medical care remained stable over the years (Figure 25).




28
                                                                                         Catalan Liver Transplant Registry. 1984-2007



Figure 25. Evolution of patient status prior to transplant, elective transplants in patients aged
15 years or over. 1992-2007

           Number of transplants
     220
     200
     180
     160
     140
     120
     100
      80
      60
      40
      20
       0
             92     93      94        95    96       97          98       99       00       01       02          03    04    05       06     07
                                                                      Year of transplant
                                      ICU        Continous hospitalization               Continous medical care and
                                                                                         at home with normal function

       Number of transplants = 2978                                                                                               Missing Data = 5




   ♦ Pretransplant risk factors

Figure 26 shows that previous upper abdominal surgery, diabetes, and obesity are
the most frequent pretransplant risk factors in transplanted patients in the 2003-2007
period.

Figure 26. Pretransplant risk factors in patients aged 15 years or over. 2003-2007

                                       Pretransplant risk factors

           Hepatic encephalopathy                                                                    12,9


  Previous upper abdominal surgery                                                                                                  20,5


            Hepatorenal syndrome                                            7,7


                           Obesity                                                                                    16,6


                  Portal thrombosis                                                           11,7


                              TIPS                     3,5


        Insulin dependent diabetes                                                                                           19,1


                                       0                     5                      10                      15               20                   25
                                                                                  Percentage of transplants

       Number of transplants = 691




                                                                                                                                                       29
Catalan Liver Transplant Registry. 1984-2007



     ♦ MELD score

The mean MELD score for transplants performed in the 2003-2007 period was 16.
In relation to the patient main disease (grouped into 3 categories: hepatocellular
carcinoma, cirrhosis, and other diseases), patients with hepatocellular carcinoma
have the lowest score (P<.0001) (Table 2).

Table 2. Mean MELD score, by type of main disease. Transplants in patients over 15 years of
age. 2003-2007

                                                                               Confidence
                                           n             Mean                   Interval                     Minim       Maxim
                                                                           lower            upper
Hepato. Carcinoma                         256             13,0              12,3             13,8                6            45
Cirrhosis                                 441             17,3              16,6             17,9                6            52
Others                                    91              18,3              16,1             20,6                6            50
Total                                     788             16,0              15,5             16,5                6            52


     ♦ Child-Pugh score

In the 2003-2007 period, 543 transplants were performed on patients with cirrhosis.
Twenty-six patients belong to group A (5-6), 210 to group B (7-9), and 163 to group C
(10-15). Most of the patients in group B presented virus C related cirrhosis, whereas
most of the patients in group C presented alcoholic cirrhosis.

Figure 27. Immunosuppressive drugs used in the first month after transplant, patients aged
15 years or over. Transplants in 1992 and 2007

           Percentage of transplants
     100



      80



      60



      40



      20



       0
            Cyclosporin    Azathioprine    Tacrolimus Mycophenoalate       Steroids         OKT3        ALS ATG      Others
                                                          Mofetil
                                                          Immunosuppressive drugs
                                                        1992 (n = 95)      2007 (n = 114)

           Only taking into account the transplants witl all the variables dealing with immunosupressors completed




30
                                               Catalan Liver Transplant Registry. 1984-2007



   ♦ Immunosuppressors

The study of immunosuppressors was carried out on the 1992 and 2007 data for
transplants where information on all drugs was available. Figure 28 shows the
distribution of the drugs used in the first month after the transplant for 1992 and
2007; there is a reduction in the use of azathioprine and cyclosporin and an increase
in the use of mycophenolate and tacrolimus.




                                                                                        31
Catalan Liver Transplant Registry. 1984-2007




Retransplants

Of the 3241 liver transplants performed between 1984 and 2007 on patients aged 15
years and over 2888 (8.9%) were retransplants (267 first retransplants and 19
second and third retransplants). Seven of these patients received their first transplant
outside Catalonia or when they were children.

Of these patients, 91.0% (2693) received only 1 transplant, 8.4% (248) received 2,
0.6% (17) received 3, and 0.1% (2) received 4.

Most retransplants were performed a year after the previous transplant, although a
quarter were performed within the first week after having undergone the previous
transplant (Figure 28).

Figure 28. Percentage of retransplants by time elapsed since the previous transplant,
patients aged 15 years or over. 1984-2007

          Percentage of retransplants
     40
                                                                                                                  36,7




     30
                   25,3
                                                                                           23,1

     20



                                            9,3
     10
                                                                  5,7



      0
                 1st week               2nd week -            2nd month -              4th month -             >1st year
                                         1st month             3rd month                 1st year
                                                     Time since previous transplant
                                                                        Seven retransplants have been excluded because the first
      Number of valid retransplants = 281                               transplant was performed outside Catalonia or in a child



The main cause of transplant failure was complications with the technique (such as
arterial thrombosis), followed by (mainly chronic) rejection (Figure 29). The
recurrence of original disease is the most common cause of long-term retransplant
(Figure 30).

With regard to the main disease of the patients who underwent a retransplant, the 3
most frequent groups of disease were cirrhosis (51.6%), hepatocellular carcinoma
(22.4%), and acute hepatic failure (11.0%). In 14.9% of cases, the underlying
disease was a metabolic disease or other less frequent liver disease.




32
                                                                                 Catalan Liver Transplant Registry. 1984-2007



Figure 29. Causes of transplant failure, patients aged 15 years or over. 1984-2007

                                Causes of transplant failure
                   Infection         0,4

    Recurrence of orig. dis.                                                                        17,1

        Extrahepatic comp.                                              10

          Technique comp.                                                                                                     24,9

                  Rejection                                                                                 19,2

       Primary non-function                                                                          17,4

        Primary dysfunction                       3,6

          Hepatitis de novo                       3,6

                     Others                      3,2

               Not available          0,7

                                0                       5          10                    15                 20              25
                                                                   Percentage of retransplants
                                                                             Seven retransplants have been excluded because the first
       Number of valid retransplants = 281                                   transplant was performed outside Catalonia or in a child



Figure 30. Percentage of retransplants by cause of transplant failure and time elapsed since
the previous transplant, patients aged 15 years or over. 1984-2007

                                 Causes of transplant failure
                    Infection

     Recurrence of orig. dis.

         Extrahepatic comp.

           Technique comp.

                   Rejection

       Primary non-function

        Primary dysfunction

           Hepatitis de novo

                      Others

               Not available

                                0%                     20%          40%                    60%                   80%             100%
                                                                  Percentage of retransplants
                       1st week            2nd week -1st month   2nd month -3rd month            4th month - 1st year   >1st year

                                                                             Seven retransplants have been excluded because the first
       Number of valid retransplants = 281                                   transplant was performed outside Catalonia or in a child




                                                                                                                                        33
Catalan Liver Transplant Registry. 1984-2007




Survival

Overall patient survival for adults who received a first liver transplant in the 184-2007
period was 84% at 1 year, 75% at 3 years, 69% at 5 years, and 56% at 10 years. For
graft survival, these figures fall to 79%, 69%, 62%, and 50%, respectively
(Figure 31).

Overall survival is conditioned by the characteristics of the transplants performed
during the first years, since the number of cases was small and this was a new
technique. Factors pertaining to the subsequent transplants, such as the inclusion of
patients with poor prognosis diseases, older patients, changes in the use of
immunosuppressors, advances in surgical and preservation techniques, etc also
conditioned survival.

Figure 31. Patient and graft survival, transplants in patients aged 15 years or over. 1984-
2007

            Probability
       1


      0,8


      0,6


      0,4


      0,2


       0
            0      1      2   3   4       5       6       7           8     9      10    11   12   13   14   15
                                                              Years
                                           Patient (n = 2946)         Graft (n = 3231)
                                  1st year       0,84                        0,79
                                  3rd year       0,75                        0,69
                                  5th year       0,69                        0,62
                                  10th year      0,56                        0,50




There was a statistically significant drop in survival in patients who had undergone
more than 1 transplant (P=.008), although the probability of survival during the first
years was not much different to that of patients who only underwent a single
transplant. At 5 and 8 years, the differences were 0.07 and 0.11, respectively
(Figure 32).


     ♦ Period in which the transplant was performed

In order to fit the results as far as possible to the context of each stage, 4 periods
were established for analyzing survival: 1984-1991, 1992-1996, 1997-2002, and
2003-2007. Statistically significant inter-period differences were found for all 4
periods in survival of both patient and graft (P<.0001) (Figures 33 and 34).



34
                                                                                   Catalan Liver Transplant Registry. 1984-2007



Figure 32. Patient survival according to number of transplants received, patients aged 15
years or over. 1984-2007

            Probability
     1


    0,8


    0,6


    0,4


    0,2


     0
           0         1           2   3   4       5      6          7           8      9         10       11       12      13       14   15
                                                                       Years
                                                                                                     only 1 tx         more than 1 tx
                                                                                                     (n = 2686)        (n = 260)
                                                                                    1st year          0,84                 0,80
      p = 0,008                                                                     3rd year          0,76                 0,70
                                                                                    5th year          0,69                 0,62
          Number of patients = 2.946                                                10th year         0,57                 0,46




Figure 33. Patient survival by period in which the first liver transplant was performed, patients
aged 15 years or over. 1984-2007

               Probability
      1


    0,8


    0,6


    0,4


    0,2


      0
            0                1       2       3              4            5            6              7            8            9        10
                                                                      Years
                                                                1984-1991          1992-1996          1997-2002         2003-2007
                                                                (n = 314)          (n = 663)          (n = 1010)        (n = 959)
                                                 1st year          0,66              0,82                0,87              0,89
      p < 0,0001                                 3rd year          0,58              0,73                0,78              0,80
                                                 5th year          0,52              0,67                0,70              0,76
          Number of patients = 2946              7th year          0,48              0,61                0,67              *




                                                                                                                                             35
Catalan Liver Transplant Registry. 1984-2007



Figure 34. Graft survival by period, transplants in patients aged 15 years or over. 1984-2007

            Probability
       1


      0,8


      0,6


      0,4


      0,2


       0
            0             1     2      3              4          5        6         7        8         9      10
                                                                Years
                                                          1984-1991     1992-1996   1997-2002    2002-2007
                                                          (n = 356)     (n = 744)   (n = 1102)   (n = 1029)
                                           1st year          0,58         0,76         0,82         0,85
        p < 0,0001                         3rd year          0,50         0,65         0,73         0,76
                                           5th year          0,44         0,59         0,65         0,70
        Number of transplants = 3231       7th year          0,40         0,53         0,62         *




The following survival analyses were carried out using data on transplants performed
from 1997 onwards, as the current course of liver transplants is more in line with
survival patterns observed in the last 2 periods.

Patient survival in the 1997-2007 period was 88% at 1 year, 79% at 3 years, 72% at
5 years, and 61% at 10 years. Graft survival at the same points was 83%, 74%, 67%
and 57%.


     ♦ Recipient age group

In the long term, older patients have a lower survival rate. Specifically, in patients
over the age of 60 years, survival at 7 years is 61% —0.09 less than for patients in
the 51-61 years of age group (Figure 35).

The differences in survival by age of recipient are statistically significant when
compared with the overall figures for the 4 groups (P<.0001). Intergroup comparison
between 2 age groups shows differences between the 31-50 years of age group and
the over 60 years of age group (P<.001) and between the 51-60 age group and the
over 60 years of age group (P=.002).


     ♦ Indications

In terms of the transplant indication, patients who presented with a metabolic disease
or cholestatic disease as an indication had a higher long-term survival rate. Patients
with hepatocellular carcinoma and those in the “others" group (tumors other than
hepatocellular carcinoma, congenital biliary disease, Budd-Chiari) had the lowest
survival rates. Differences between the different indications were statistically
significant (P=.001) (Figure 36).


36
                                                                           Catalan Liver Transplant Registry. 1984-2007



Figure 35. Patient survival by age group in which the first liver transplant was performed,
patients aged 15 years or over. 1997-2007

          Probability
      1


    0,8


    0,6


    0,4


    0,2


      0
          0                1         2           3                4               5           6             7              8
                                                                 Years
                                                                       15-30      31-50       51-60         > 60
                                                                       (n = 74)   (n = 550)   (n = 734)     (n = 611)
                                                      1st year          0,86        0,91        0,89          0,83
      p < 0,0001                                      3rd year          0,81        0,82        0,80          0,74
                                                      5th year          0,78        0,77        0,72          0,65
      Number of patients = 1969                       7th year          0,78        0,74        0,70          0,61




Figure 36. Patient survival by indication, patients aged 15 years or over. 1997-2007

          Probability
      1


    0,8


    0,6


    0,4


    0,2


      0
          0               1          2            3                4              5           6             7              8
                                                                 Years
                                   AHF        Cholestatic D        Cirrhosis      HCC         Metabolic D       Others
    p = 0,001
                                   (n = 79)    (n = 75)            (n = 1044)     (n = 648)    (n = 78)         (n = 45)
                        1st year   0,74          0,90                0,88           0,88        0,96             0,82
    Number of           3rd year   0,71          0,89                0,79           0,77        0,93             0,71
    patients =          5th year   0,68          0,86                0,72           0,69        0,86             0,67
    1969                7th year   0,68          0,86                0,68           0,66        0,84             *




                                                                                                                               37
Catalan Liver Transplant Registry. 1984-2007



Patients with hepatocellular carcinoma and cirrhosis had very similar survival rates.
After the first year, patients with cirrhosis had a slightly higher survival rate than
patients with hepatocellular carcinoma and survival at 5 years was 72% for patients
with cirrhosis and 69% for patients with a tumor (P=.535).

In terms of graft survival, there was a reduction in survival in the first 2 years
following transplant in patients with cholestatic disease as an indication (Figure 37).

Figure 37. Graft survival by indication, transplants in patients aged 15 years or over. 1997-
2007

             Probability
         1


       0,8


       0,6


       0,4


       0,2


         0
             0               1           2           3            4            5           6             7              8
                                                                 Years
                                      AHF        Cholestatic D    Cirrhosis    HCC         Metabolic D       Others
      p = 0,001
                                      (n = 92)    (n = 87)        (n = 1126)   (n = 694)    (n = 82)         (n = 50)
                           1st year    0,69          0,84            0,84         0,84        0,94             0,75
     Number of             3rd year    0,66          0,81            0,74         0,73        0,91             0,66
     transplants =         5th year    0,62          0,75            0,67         0,64        0,83             0,62
     2131                  7th year    0,62          0,75            0,63         0,61        0,80             0,62




Comparison of survival in patients with alcoholic cirrhosis, viral cirrhosis and
hepatocellular carcinoma, with no other associated disease showed statistically
significant differences (P=.012). There were no statistically significant differences
between viral cirrhosis and hepatocellular carcinoma (P=.205) (Figure 38).


      ♦ Donor age

Patient survival by first-transplant donor age group showed no statistically significant
differences (P=.086), although patients receiving organs from younger donors had a
higher survival rate than patients receiving organs from older donors (Figure 39).




38
                                                           Catalan Liver Transplant Registry. 1984-2007



Figure 38. Patient survival by indication (3 groups), patients aged 15 years or over. 1997-
2007

              Probability
     1


    0,8


    0,6


    0,4


    0,2


     0
           0                1        2   3          4              5            6              7          8
                                                 Years

                                                         Alcoholic Cir   Virus related Cir    HCC
                                                         (n = 362)       (n = 476)            (n = 648)
                                             1st year       0,90             0,85            0,88
         p = 0,012                           3rd year       0,83             0,75            0,77
                                             5th year       0,78             0,66            0,69
         Number of patients = 1486           7th year       0,75             0,62            0,66




Figure 39. Patient survival by donor age group, patients aged 15 years or over with first
elective transplant. 1997-2007

           Probability
     1


   0,8


   0,6


   0,4


   0,2


     0
          0                 1        2   3         4               5            6              7          8
                                                 Years

                                                                0-55          56-65          > 65
                                                                (n = 1127)    (n = 354)      (n = 405)
     p = 0,086                                      1st year      0,89          0,87           0,88
                                                    3rd year      0,81          0,77           0,76
     Number of patients = 1886                      5th year      0,74          0,69           0,69
                                                    7th year      0,72          0,65           0,62




Statistically significant differences (P=.022) were found in graft survival in the overall
and intergroup comparisons, except between the 56-65 years group and the over 65
years group (Figure 40).



                                                                                                              39
Catalan Liver Transplant Registry. 1984-2007



Figure 40. Graft survival by donor age group, patients aged 15 years or over with first elective
transplant. 1997-2007

             Probability
      1


     0,8


     0,6


     0,4


     0,2


      0
            0              1              2   3    4            5             6            7           8
                                                  Years
                                                               0-55           56-65        > 65
                                                               (n = 1196)     (n = 374)    (n = 422)
            p = 0,022
                                                    1st year     0,85           0,82         0,84
                                                    3rd year     0,77           0,72         0,71
           Number of transplants = 1992
                                                    5th year     0,70           0,63         0,63
                                                    7th year     0,68           0,58         0,56




     ♦ Type of donor

No statistically significant differences were found in graft survival between donor
types (brain-death cadaveric, living, and domino), although, in the short term, survival
appeared to be better in domino transplants (Figure 41).

Figure 41. Graft survival by donor type, elective transplants in patients aged 15 years or over.
1999-2007

             Probability
      1


     0,8


     0,6


     0,4


     0,2


      0
            0              1              2   3     4           5             6             7          8
                                                  Years

                                                               Cadaveric BD     Living      Domino
                                                               (n = 1526)       (n = 60)    (n = 58)
                                                    1st year     0,85         0,88          0,93
           p = 0,627                                3rd year     0,76         0,71          0,80
                                                    5th year     0,69         0,71          0,69
           Number of transplants = 1644             7th year     0,64         *             *



40
                                                          Catalan Liver Transplant Registry. 1984-2007



   ♦ Cause of donor death

No statistically significant differences were observed (P=.456) in patient survival
between causes of donor death, although patients who received an organ from
donors who had died due to traumatic brain damage (TBD) had a higher survival rate
(Figure 42).

Figure 42. Patient survival by cause of donor death, patients aged 15 years or over with first
elective transplant. 1997-2007

          Probability
      1


    0,8


    0,6


    0,4


    0,2


      0
          0             1         2     3          4            5           6            7        8
                                                 Years
                                                  TBD         Stroke       Anoxia      Others
                                                  (n = 522)   (n = 1021)   (n = 131)   (n = 68)
    p = 0,456                         1st year   0,88         0,89          0,85          0,84
                                      3rd year   0,81         0,79          0,76          0,76
     Number of patients = 1.742
                                      5th year   0,75         0,71          0,68          0,65
     Missing data = 10
                                      7th year   0,73         0,67          0,64          0,65



Differences in graft survival by cause of donor death were not statistically significant
(P=.109); long-term survival was higher for transplants from donors who had died
due to TBD than in transplants from donors who had died due to stroke and there
were significant differences between these groups (P=.04) (Figure 43).


   ♦ Urgency

Patients who had received an urgent transplant had a 0.13 lower survival rate at 1
year than other patients, although survival at 7 years was almost the same as that for
patients who received an elective transplant (P=.001) (Figure 44).

The differences are greater for graft survival (P<.0001). Even at 7 years, the survival
rate was 0.08 higher for non-urgent transplants (Figure 45).




                                                                                                      41
Catalan Liver Transplant Registry. 1984-2007



Figure 43. Graft survival by cause of donor death, elective transplants in patients aged 15
years or over. 1997-2007

           Probability
      1


     0,8


     0,6


     0,4


     0,2


      0
           0             1           2     3          4            5            6            7        8
                                                    Years
                                                    TBD         Stroke       Anoxia       Others
                                                    (n = 551)   (n = 1084)   (n = 137)    (n = 73)
     p = 0,109                           1st year   0,86         0,84          0,80           0,79
                                         3rd year   0,78         0,74          0,71           0,72
     Number of transplants = 1.845       5th year   0,72         0,66          0,61           0,62
     Missing data = 11                   7th year   0,70         0,61          0,57           0,62



Figure 44. Patient survival by urgency, patients aged 15 years or over. 1997-2007

           Probability
      1


     0,8


     0,6


     0,4


     0,2


      0
           0             1           2     3          4           5            6             7        8
                                                    Years
                                                                             Urgent      Elective
                                                                             (n = 82)    (n = 1886)
       p = 0,001                                                  1st year     0,73         0,88
                                                                  3rd year     0,69         0,79
       Number of patients = 1968
                                                                  5th year     0,67         0,72
       Missing data = 1
                                                                  7th year     0,67         0,69




42
                                                      Catalan Liver Transplant Registry. 1984-2007



Figure 45. Graft survival by urgency, transplants in patients aged 15 years or over. 1997-
2007

            Probability
     1


    0,8


    0,6


    0,4


    0,2


     0
           0              1           2   3     4          5              6           7         8
                                              Years
                                                                       Urgent      Elective
                                                                       (n = 137)   (n = 1992)
      p < 0,0001                                           1st year      0,69        0,84
                                                           3rd year      0,64        0,75
      Number of transplants = 2129                         5th year      0,56        0,67
      Missing data = 2                                     7th year      0,56        0,64




Figure 46. Patient survival by blood-group compatibility, patients aged AB0 years or over with
first elective transplant. 1997-2007

            Probability
     1


    0,8


    0,6


    0,4


    0,2


     0
           0              1           2   3    4          5              6           7          8
                                              Years

          p = 0,686                                                   Isogroup     Compatible
                                                                      (n = 1850)   (n = 31)
          Number of patients = 1881                       1st year       0,88          0,90
          Missing data = 3                                3rd year       0,79          0,72
                                                          5th year       0,72          0,62
                                                          7th year       0,69          0,62




   ♦ Blood group compatibility

Patients who received an organ from a donor with the same blood type had a higher
survival rate than those for whom compatibility was not identical, although the


                                                                                                    43
Catalan Liver Transplant Registry. 1984-2007



differences were not statistically significant (Figure 46). Differences were also not
statistically significant in terms of graft survival (Figure 47). The low number of non-
identical compatible cases and the exclusion of incompatible cases should be taken
into consideration.

Figure 47. Graft survival by blood-group compatibility, elective transplants in patients aged 15
years. 1997-2007

             Probability
      1


     0,8


     0,6


     0,4


     0,2


      0
            0                 1           2   3    4           5             6            7           8
                                                  Years

           p = 0,676                                                       Isogroup      Compatible
                                                                           (n = 1950)    (n = 37)
           Number of transplants = 1987                        1st year       0,84          0,86
           Missing data = 5                                    3rd year       0,75          0,67
                                                               5th year       0,68          0,58
                                                               7th year       0,64          0,58



Figure 48. Graft survival by cold ischemia time, transplants in patients aged 15 years or over.
1997-2007

                Probability
       1


     0,8


     0,6


     0,4


     0,2


       0
             0                1           2   3     4          5              6            7          8
                                                  Years
                                                               <6h           6-9 h       >9h
                                                               (n = 837)     (n = 807)   (n = 339)
           p = 0,003                                1st year   0,87           0,84         0,79
                                                    3rd year   0,77           0,75         0,69
           Number of transplants = 1983             5th year   0,69           0,69         0,62
           Missing data = 9
                                                    7th year   0,63           0,67         0,61




44
                                            Catalan Liver Transplant Registry. 1984-2007



  ♦ Ischemia time

Overall, the differences in graft survival according to number of hours of cold
ischemia were statistically significant (P=.003), but there were no differences
between transplants with a duration of ischemia of less than six hours and
transplants where ischemia lasted for between six and nine hours (Figure 48).




                                                                                     45
Catalan Liver Transplant Registry. 1984-2007




Mortality

Of the 2960 adult patients in the record, 61.4% (1818) were still alive at 31 December
2007 and 37.0% (1096) had died. This information was not available for 1.6% (46) as
follow-up had been discontinued.

Death occurred in the first month after the first transplant in 14.4% (158) of cases
(Figure 49).

Figure 49. Deceased patients by time elapsed between first transplant and death, patients
aged 15 years or over. 1984-2007

          Percentage of patients
     70

     60                                                                                                        57,5


     50

     40

     30

     20                                                                                17,6

                                                             10,4
     10                                8,3
                    6,1


      0
                 1st week          2nd week -            2nd month -               4th month -              >1st year
                                    1st month             3rd month                  1st year
                                                Time since the first transplant

                                                                    Two patients have been excluded because the first
      Number of deceased patients = 1094                            transplant was performed outside Catalonia or in a child




The main causes of death in adult patients were recurrence of the primary disease
(28.4%) and infections (17.6%) (Figure 50 and Figure 51).

Recurrence of the primary disease, infections, extrahepatic complications, and de
novo tumors are the main cause of death in adult patients who received just one liver
transplant. Recurrences, infections and extrahepatic complications are also the main
cause of death in patients who received a second transplant, followed, in this case,
by rejection and technique complications (Table 3).




46
                                                                                   Catalan Liver Transplant Registry. 1984-2007



Figure 50. Cause of death in patients aged 15 years or over. 1984-2007

                                 Causes of death
                    Infection                                                                   17,6

    Recurrence of orig. dis.                                                                                                          28,4

        Extrahepatic comp.                                                      12,8

             Tumor de novo                                              10,1

          Technique comp.                       2,6

        Intraoperative death                    2,6

                   Rejection                                6,2

       Primary non-function           1

        Primary dysfunction               1,7

          Hepatitis de novo               1,8

                     Others                                                    12,5

               Not available                    2,7

                                0                     5            10                  15              20            25                 30
                                                                           Percentage of patients

                                                                               Two patients have been excluded because the first
      Number of deceased patients = 1094                                       transplant was performed outside Catalonia or in a child




Figure 51. Percentage of deceased patients by cause of death and time elapsed between
first transplant and death, patients aged 15 years or over receiving only one transplant. 1984-
2007.

                                Causes of death
                   Infection
    Recurrence of orig. dis.
        Extrahepatic comp.
             Tumor de novo
          Technique comp.
        Intraoperative death
                   Rejection
       Primary non-function
        Primary dysfunction
          Hepatitis de novo
                     Others
               Not available
                                0%                    20%                40%                60%                80%                    100%
                                                                          Percentage of patients

                   1st week          2nd week -1st month          2nd month -3rd month        4th month - 1st year        >1st year

      Number of deceased patients = 957




                                                                                                                                             47
Catalan Liver Transplant Registry. 1984-2007



Table 3. Evolution of cause of death by number of transplants received, patients aged 15
years or over. 1984-2007

                                               1st transplant        2nd transplant
                                               n           %         n           %
Infection                                  157            16,4      31          24,6
Recurrence of original disease             283            29,6      25          19,8
Extrahepatic complications                 123            12,9      16          12,7
Tumor de novo                              105            11,0       5          4,0
Technique complications                        20         2,1        8          6,3
Intraoperative death                           22         2,3        6          4,8
Rejection                                      56         5,9       11          8,7
Primary non-function ( < 8 d)                  7          0,7        3          2,4
Primary dysfunction (> 7 dies)                 17         1,8        2          1,6
Hepatitis de novo                              16         1,7        4          3,2
Others                                     123            12,9      14          11,1
Not available                                  28         2,9        1          0,8
Total                                      957           100,0      121        100,0




48
                                                                             Catalan Liver Transplant Registry. 1984-2007




Waiting List

Both the number of transplants and the number of patients on the waiting list at the
end of the year have remained quite stable for the past eight years (Figure 52).

Figure 52. Evolution of number of transplants and number of patients on waiting list at end of
year, patients aged 15 years or over. 2000-2007


    250
                                                          221                                217
                                                                                                                   203
                               195                                          195                             195
    200                                  190
                   176


    150
                                                                            129                                    129

                   103                                    100                                               100
                                          97                                                  95
    100                        86



     50



         0
             2000             2001      2002             2003              2004             2005            2006     2007
                                                                    Year
                                      Annual number of transplants         Waiting list patients at 31-12

      Source: Registry of donor and patients awaiting transplant.



Figure 53. Evolution of mortality rate on waiting list, patients aged 15 years or over. 2000-
2007

             Mortality rate
    12


    10
                                                                            9,7
                              8,8
     8

                                        7,2               7
     6                                                                                       6,3
               6
                                                                                                            5,2
     4

                                                                                                                   2,9
     2


     0
         2000                 2001     2002             2003               2004             2005            2006     2007
                                                                Year

      Source: Registry of donor and patients awaiting transplant.




                                                                                                                            49
Catalan Liver Transplant Registry. 1984-2007



In 2007, the mean number of days waiting for a liver transplant in adults was 135
days. Excluding urgent transplants, waiting time was 145 days. These values have
remained stable over the years.

In 2007, 254 adults were included in the list and 225 were excluded. The percentage
of transplants on the list was 57.7%. Of the exclusions, 10 were due to death, giving
a mortality rate of 2.9% on the waiting list. Mortality on the waiting list fell in the last
two years (Figure 53).

In the 2000-2007 period, the probability of receiving a liver transplant was 53% after
6 months on the waiting list and 74% after 1 year (Figure 54).

Figure 54. Cumulative probability of receiving a liver transplant, patients aged 15 years or
over. 2000-2007


           Probability
      1



     0,8



     0,6



     0,4



     0,2



      0
           0     1       2   3     4      5     6      7      8      9    10       11   12   13   14   15   16   17   18
                                                           Weeks on waiting list

       Source: Registry of donor and patients awaiting transplant.




50
                                                                                Catalan Liver Transplant Registry. 1984-2007




Liver Transplants in Children
Of the 3453 transplants performed in Catalonia between 1984 and 2007, 212 were in
patients under 15 years (179 first transplants and 33 retransplants).

Eight transplants were performed in 2007: six first transplants and two retransplants.

Pediatric transplant activity varies from year to year and we found no clear rising or
falling rend for this activity (Figure 55).

Figure 55. Evolution of number of liver transplants, patients under the age of 15 years. 1984-
2007

       Number of transplants
 20
                                   18
 18
                                             16
 16
                                                              14                                        14
 14                                                     13                                    13
                  12
 12
                                        10                                               10                          10   10
 10                                                                        9                                 9
                                                                                                                               8
  8                    7                           7                                                             7

  6                            5                                                                    5
                                                                    4                4
  4          3                                                                  3

  2     1

  0
        84 85 86 87 88 89 90 91                   92 93 94 95 96 97 98 99                     00 01 02 03 04 05 06 07
                                                              Year of transplant
                                             First transplants (n = 179)       Retransplants (n = 33)

        Number of transplants = 212




Recipient characteristics

      ♦ Gender and age

52.5% (94) of patients who received a first transplant were boys and 47.5% (85) were
girls.

The mean age for the entire period was 4.5 years (95% CI=3.9-5.2, range=1.5
months-14 years). 48,6% (87) of patients who received a first transplant were aged
between 0 and 2 years.

      ♦ Indications

Diseases indicated for transplant are grouped into six categories: acute hepatic
failure (AHF), cholestatic disease, congenital biliary disease, cirrhosis, tumors,
metabolic diseases, and others (Budd-Chari and polycystic liver disease), according
to the code recorded in the main diagnosis.


                                                                                                                                   51
Catalan Liver Transplant Registry. 1984-2007



Congenital biliary disease (mostly biliary atresia, 93 of 99 cases) was the indication in
55.3% (99) of patients (Figure 56). 68.7% (68) of children with this group of diseases
were aged between 0 and 2 years (Figure 57).

Figure 56. Main diagnosis for first liver transplant, patients under the age of 15 years. 1984-
2007




                                                                                       Cholestatic diseases
                                                                                              3,4%

                   Congenital biliary dis                                                        Acute hepatic failure
                        55,3%                                                                           12,3%




                                                                                                   Others
                                                                                                   2,8%




                                                                                            Metabolic diseases
                                                                                                 17,9%

                                                            Cirrhosis Tumors
                                                              5,6% 2,8%

            Number of patients = 179




Figure 57. Main diagnosis for first liver transplant by age group, patients under the age of 15
years. 1984-2007

            Number of patients
     80

     70

     60

     50

     40

     30

     20

     10

     0
                     0-2 years                  3-5 years                      6-9 years                      10-14 years
                      (n = 87)                   (n = 24)                       (n = 35)                        (n = 33)
                                                                Age group

                                 AHF        Cholestatic dis.      Congenital biliary dis.       Cirrhosis
                                 Tumors     Metabolic dis.        Others

          Number of patients = 179




52
                                                                          Catalan Liver Transplant Registry. 1984-2007



The proportion of patients who received a transplant due to a congenital biliary
disease or a metabolic disease has remained stable over the years. The trend for the
rest of liver diseases could not be observed due to the low number of cases
(Figure 58).

Figure 58. Main diagnosis for first liver transplant by period, patients under the age of 15
years. 1984-2007

           Number of patients
    35

    30

    25

    20

    15

    10

     5

     0
                   1984-1991                 1992-1996                         1997-2002                 2003-2007
                     (n = 60)                  (n = 40)                          (n = 43)                  (n = 36)
                                                          Year of transplant

                                    AHF      Cholestatic dis.      Congenital biliary dis.   Cirrhosis
                                    Tumors   Metabolic dis.        Others

         Number of patients = 179




Donor characteristics

   ♦ Gender and age

The mean donor age for the 1992-2007 period was 15 years (95% CI=12.6-17.6,
range=1-58). Over the years, the mean age has varied with a slight tendency to
increase due to the gradual increase in the maximum donor age.

60.0% of donors were men and 40.0% were women.


   ♦ Type of donor

The first living donor transplant was performed in 2003. A total of 5 of these
transplants have been performed (1 in 2003, 3 in 2004, and 1 in 2005). Organs from
living donors represent only 3.6% of all organs transplanted in the 1992-2007 period;
the remaining 96.4% (135) come from cadaveric donors.




                                                                                                                      53
Catalan Liver Transplant Registry. 1984-2007



     ♦ Cause of death

In the 1992-2007 period, 49.2% of donors died due to craneoencephalic trauma,
27.3% due to cerebrovascular accident,12.9% due to anoxia and 10.6% due to other
causes.


     ♦ Origin

14.4% of donors for pediatric transplants carried out between 1992 and 2007 were
from the same hospital and 27.0% from another hospital in Catalonia, whereas
47.7% were from the rest of Spain and 10.8% from abroad. This information was
unavailable in 29 cases.



Transplant Characteristics

     ♦ Urgency

Of the 212 transplants performed in 1984-2007 period, 21.8% were urgent. 53.5% of
these transplants were first transplants and 46.5% were retransplants.


     ♦ Type of transplant

A full size organ from a cadaveric donor was used in 69.9% (146) of the pediatric
transplants performed during the 1984-2007 period, a reduced organ was used in
16.7% (35) of cases, and a split organ was used in 11.0% (23) of cases. Reduced
living donor transplants represent only 2.4%.


     ♦ Ischemia time

The mean duration of ischemia in pediatric transplants carried out in the 1984-2007
period was 6.8 hours (SD ± 2.6, range=2.5-20.0).



Retransplants

Of the 212 pediatric transplants carried out in the 1984-2007 period, 33 (15.6%) were
retransplants (179 first transplants, 29 second transplants and 4 third transplants).
Four patients required a transplant after the age of 15 years.

Of these patients, 83.8% (150) received only 1 transplant, 14.0% (25) received 2,
and the remaining 2.2% (4) received 3.

Of the 33 failed transplants, 10 (30.3%) failed in the first week, 10 (30.3%) after the
first week and in the first 3 months, 5 (15.2%) after the fourth month and in the first
year and the remaining 8 (24.2%) after the first year.




54
                                                                            Catalan Liver Transplant Registry. 1984-2007



The main cause of failure was rejection (11 cases, 33.3%), followed by primary
malfunction (9 cases, 27.3%) and technique complications (9 cases, 27.3%). Primary
malfunction was the cause of failure in most of the transplants that failed in the first
month, whereas chronic rejection was the main cause where failure occurred at a
later stage.



Survival

77% of the children under 15 who received a liver transplant during the 1984-2007
period survived to 1 year after the operation and 63% had survived at 10 years
(Figure 59). Graft survival was slightly lower than patient survival (0.10 lower at 1
year and 0.09 at 10 years).

Figure 59. Patient and graft survival, patients under the age of 15 years. 1984-2007

          Probability
      1


    0,8


    0,6


    0,4


    0,2


      0
          0      1      2   3    4          5       6      7            8       9         10   11   12   13   14   15
                                                                Years
                                            Patient (n = 179)           Graft (n = 212)
                                1st year        0,77                          0,67
                                3rd year        0,72                          0,61
                                5th year        0,67                          0,57
                                10th year       0,63                          0,51




   ♦ Period in which the transplant was performed

When survival was analyzed by the period in which the transplant was performed,
survival rates at 1 and 3 years were found to increase considerably in the later
periods (Figure 60). The overall difference was statistically significant (P=.001) but
the inter-period differences were not significant.




                                                                                                                        55
Catalan Liver Transplant Registry. 1984-2007



Figure 60. Patient survival by period, patients under the age of 15 years. 1984-2007

            Probability
       1


      0,8


      0,6


      0,4


      0,2


       0
            0             1        2   3              4          5              6          7           8             9     10
                                                                Years
                                                          1984-1991       1992-1996         1997-2002         2003-2007
                                                          (n = 60)        (n = 40)          (n = 43)          (n = 36)
                                           1st year          0,65           0,78               0,86              0,88
        p = 0,001                          3rd year          0,58           0,68               0,84              0,84
                                           5th year          0,50           0,63               0,84              *
        Number of patients = 179           7th year          0,48           0,63               0,84              *




     ♦ Indications

Due to the small number of transplants carried out in children, it was not possible to
analyze survival in the different indicator disease groups. Two groups were therefore
created: patients with congenital biliary disease and those without.

Figure 61. Patient survival by indication (congenital biliary liver disease or others), patients
under the age of 15 years. 1992-2007

            Probability
       1


     0,8


     0,6


     0,4


     0,2


       0
            0             1        2   3          4              5              6          7           8             9     10
                                                              Years

                                                                                    Cong biliary dis       Others indic.
                                                                                    (n = 66)               (n = 53)
                                                                     1st year        0,88                    0,79
        p = 0,085                                                    3rd year        0,85                    0,70
                                                                     5th year        0,83                    0,68
        Number of patients = 119                                     7th year        0,83                    0,68




56
                                                                               Catalan Liver Transplant Registry. 1984-2007



Children who received a liver transplant in the 1992-2007 period due to a congenital
biliary disease had a higher survival rate than children with other indications. The
differences between the two groups were statistically significant (Figure 61).



Mortality

Of the 179 patients who underwent a transplant, 65.9% (118) were still alive at 31
December 2007 and 34.1% (61) had died.

Of the 61 patients who died, 21 (34.4%) had died within the first month following the
first transplant and 21 (34.4%) died after the first year.

The most frequent causes of death were infection and extrahepatic complications
(Figure 62).

Figure 62. Cause of death, patients under the age of 15years. 1984-2007

                               Causes of death

                   Infection                                                                     36,1

    Recurrence of orig. dis.                                     9,8

       Extrahepatic comp.                                                   21,3

            Tumor de novo          1,6

          Technique comp.                            6,6

       Intraoperative death        1,6

                  Rejection              3,3

      Primary non-function                                 8,2

       Primary dysfunction                     4,9

                     Others                          6,6

                               0                           10          20                 30            40         50
                                                                       Percentage of patients
      Number of deceased patients = 61




Waiting List

In the 2000-2007 period, 101 patients were included in the waiting list, of whom 76
(75.2%) received a transplant, 6 died while awaiting a transplant, and the rest were
excluded due to improvement or deterioration.

Fourteen patients were included in the list in 2007 and 7 of them remained on the list
at 31 December.




                                                                                                                        57

								
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