20-year survival post-liver transplant: much more is needed!

The manuscript entitled ‘‘Analysis of adult 20-year survivors after liver transplantation [1]’’ from a single centre in Barcelona, Spain, assessed the outcome and liver function of survivors 20 years after liver transplantation, together with the cause of death in those who did not survive to reach this milestone. There were 132 adult patients who received 151 liver transplants from deceased donors. During the first year, there were 41 recipients who died, with a further 41 deaths by 5 years and a further 22 who had succumbed by 20 years, leaving only 28 patients (21 %), approximately one in five of the recipients surviving to 20 years. There are some discrepancies in the article which are difficult for the reader to reconcile. In the segment on patient and graft survival, the ‘‘overall actuarial 5, 10 and 20 year patient survival rates were 48, 38 and 22 % respectively.’’ According to the numbers presented in Table 5, the 1-, 5and 20-year survivals were 69, 38 and 21 %, respectively, which are different from the aforementioned. In addition, in listing the causes of death in Table 5, the percentages listed at\1 year, 1–5 years and 5–20 years are values for 104 deaths and not percentage of deaths compared to the number of recipients, i.e. 41 (31 %) of 132 recipients during the first year, 41 (31 %) of 132 recipients during years 1–5, and 22 (17 %) of 132 recipients who died between 5 and 20 years. In the discussion section—‘‘On analysing the characteristics of our 20 year survivors, hepatitis C cirrhosis was the main indication in both groups (36 vs 34 % in non20 year survivors)’’—these percentages are related to the number of HCV survivors and non-survivors compared with the total number of recipients in each group, rather than the % of HCV survivors and non-survivors at 20 years (22 vs 78 %, respectively). This certainly negates the statement ‘‘The younger age of donors in that period could explain the unexpected long-term survival from hepatitis C in 20 year survivors,’’ which was 22 and not 36 % as stated. Among the conditions listed in Table 2, comparing donor and surgery characteristics of 20-year survivors and non-survivors, is portal thrombosis. As it is not defined, one has to assume that this is in the recipient and presumably pre-implantation, as it lists 20 such cases, while in the main postoperative complications in Table 3 only three cases of portal vein thrombosis are listed. The study group comprised all adult patients transplanted between October 1988 and May 1993 during which 132 patients received 151 transplants. Twenty-eight patients (21 %) survived to 20 years. The main cause of death posttransplant was infections, which accounted for 57 % in the first 5 years, and the question of over-immunosuppression in the early period of transplant programs is raised. Maintenance immunosuppression in the present study group was cyclosporine and prednisone together with azathioprine, whereas tacrolimus was not initiated until 1993 and has had a significant impact in other studies where rates of acute or chronic rejection are significantly lower and graft loss from rejection has become relatively rare. The main causes of death were infections in the first 5 years, with HCV recurrence, de novo malignancy and cardiovascular events in the later years of follow-up. Longterm complications in 20-year survivors included arterial hypertension, diabetes mellitus, dyslipidemia and renal dysfunction, together with de novo malignancy. All these parameters are similar to other studies [2]. R. Strong (&) J. Fawcett HPB and Liver Transplant Unit, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane 4102, Australia e-mail: [email protected]