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Response to Letter “Systematic Grading of Morbidity After Living Donation for Liver Transplantation”

2009; Elsevier BV; Volume: 137; Issue: 5 Linguagem: Inglês

10.1053/j.gastro.2009.05.071

1528-0012

Chris E. Freise, R. Mark Ghobrial,

Organ Donation and Transplantation

One of the primary aims of the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) is the analysis of short- and long-term outcomes in living liver donors. We have adopted the use of the severity grading system for complications described by Clavien in 1994 and still believe it is the best grading system available to classify donor complications. The A2ALL report on the complication rates and grading of complications was published in this journal in 2008.1Ghobrial R.M. Freise C.E. Trotter J.F. et al.Donor morbidity after living donation for liver transplantation.Gastroenterology. 2008; 135: 468-476Abstract Full Text Full Text PDF PubMed Scopus (334) Google Scholar We appreciate the comments by Tamura et al2Tamura S. Sugawara Y. Kukudo N. et al.Systematic grading of morbidity after living donation for liver transplantation. Letter to the editor.Gastroenterology. 2008; 135: 1804Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar regarding the systematic grading of donor complications in live liver donors and the availability of a newer classification system. The original grading system proposed by Clavien in 1992 was revised in 1994 for application to liver transplantation.3Clavien P.A. Camargo C.A. Coxford R. et al.Definition and classification of negative outcomes in solid organ transplantation Application in liver transplantation.Ann Surg. 1994; 220: 109-120Crossref PubMed Scopus (299) Google Scholar This grading system had been further utilized by Salvalaggio et al4Salvalaggio P.R.O. Baker T.A. Koffron A.J. et al.Comparative analysis of live liver donation risk using a comprehensive grading system for severity.Transplantation. 2004; 77: 1765-1767Crossref PubMed Scopus (35) Google Scholar and Ghobrial et al5Ghobrial R.M. Saab S. Lassman C. et al.Donor and recipient outcomes in right lobe adult living donor liver transplantation.Liver Transplant. 2002; 8: 901-909Crossref PubMed Scopus (107) Google Scholar to specifically address living liver donor complications. In addition, the Vancouver International Forum on Live Donation chaired by Delmonico supported this system's use in 2006.6Barr M.L. Belghiti J. Villamil F.G. et al.A report of the Vancouver Forum on the care of the live organ donor: lung, liver, pancreas, and intestine data and medical guidelines.Transplantation. 2006; 81: 1373-1385Crossref PubMed Scopus (287) Google Scholar We chose to utilize this accepted system at the start of the A2ALL retrospective data collection in 2002. Data collection was designed to allow for classification according to this system. The newer classification system reported by Clavien in 20047Dindo D. Demartines N. Clavien P.A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.Ann Surg. 2004; 240: 205-213Crossref PubMed Scopus (21649) Google Scholar was not available when the retrospective study and data collection forms were designed, and the collected data were not adequate to completely translate into the newest grading system. It is important to note the differences between the system used in the A2ALL report and the newer Clavien system. Grade 1 and grade 2a complications in the older system still correspond to grades 1 and 2 in the newer system. Grade 2b complications are now categorized as grade 3, that is, requiring operative, endoscopic, or radiologic intervention. The newer system now categorizes grade 4 complications as life-threatening, requiring intensive care unit management, and reserves grade 5 for death of a patient (previous grade 4b). Therefore, it is possible to compare the lower graded and most severely graded complications between the 2 systems. Another important change in the new system is the elimination of long-term disability as a specific criterion for a grade, and the use of the appended letter “d” to any grade complication to indicate an ongoing disability. The newer system also relies more on the type of intervention and degree of organ dysfunction, which may allow for this system to be applied across different health systems. The discussion with potential live liver donors about risks and benefits requires a careful review of the complications that have now been well quantified by the A2ALL donor report, as well as by other single-center reports. Having a reproducible grading system allows for more systematic documentation of the severity of complications, for better comparison between different reports of living liver transplantation, and comparison with other operative procedures. If the international transplant community reaches consensus that the newer system should be adopted, consideration could be given to its use in future studies designed by the A2ALL Study Group. However, A2ALL reports on complications using data from existing A2ALL protocols involving either donors or recipients will continue to utilize the 1994 version of the Clavien grading system. The following individuals were instrumental in the planning, conduct and/or care of patients enrolled in this study at each of the participating institutions as follows. Columbia University Health Sciences, New York, NY (DK62483). PI: Jean C. Emond, MD; Co-PI: Robert S. Brown, Jr, MD, MPH; Study Coordinators: Rudina Odeh-Ramadan, PharmD; Scott Heese, BA Northwestern University, Chicago, IL (DK62467). PI: Michael M.I. Abecassis, MD, MBA; Co-PI: Laura M. Kulik, MD; Study Coordinator: Patrice Al-Saden, RN, CCRC University of Pennsylvania Health System, Philadelphia, PA (DK62494). PI: Abraham Shaked, MD, PhD; Co-PI: Kim M. Olthoff, MD; Study Coordinators: Brian Conboy, PA, MBA; Mary Shaw, RN, BBA University of Colorado Health Sciences Center, Denver, CO (DK62536). PI: Gregory T. Everson, MD; Co-PI: Igal Kam, MD; Study Coordinators: Carlos Garcia, BS, Anastasia Krajec, RN University of California Los Angeles, Los Angeles, CA (DK62496). PI: Johnny C. Hong, MD; Co-PI: Ronald W. Busuttil, MD, PhD; Study Coordinator: Janet Mooney, RN, BSN University of California San Francisco, San Francisco, CA (DK62444). PI: Chris E. Freise, MD, FACS; Co-PI: Norah A. Terrault, MD; Study Coordinator: Dulce MacLeod, RN; Vivian Tan, MD University of Michigan Medical Center, Ann Arbor, MI (DK62498). PI: Robert M. Merion, MD; DCC Staff: Anna S.F. Lok, MD; Akinlolu O. Ojo, MD, PhD; Brenda W. Gillespie, PhD; Margaret Hill-Callahan, BS, LSW; Terese Howell, BS; Lan Tong, MS; Tempie H. Shearon, MS; Karen A. Wisniewski, MPH; Monique Lowe, BS University of North Carolina, Chapel Hill, NC (DK62505). PI: Paul H. Hayashi, MD, MPH; Study Coordinator: Tracy Russell, MA University of Virginia (DK62484). PI: Carl L. Berg, MD; Co-PI: Timothy L. Pruett, MD; Study Coordinator: Jaye Davis, RN Medical College of Virginia Hospitals, Virginia Commonwealth University, Richmond, VA (DK62531). PI: Robert A. Fisher, MD, FACS; Co-PI: Mitchell L. Shiffman, MD; Study Coordinators: Andrea Lassiter, Transplant data analyst; April Ashworth, RN National Institute of Diabetes and Digestive and Kidney Diseases, Division of Digestive Diseases and Nutrition, Bethesda, MD. James E. Everhart, MD, MPH; Leonard B. Seeff, MD; Patricia R. Robuck, PhD; Jay H. Hoofnagle, MD ReplyGastroenterologyVol. 137Issue 5PreviewWe appreciate the interest that our concern1 has generated regarding the application of the Clavien system for surgical complications in the A2ALL study. We admire the philosophy and the achievements of the multicenter A2ALL study group, and will continue to follow their reports with keen interest. Morbidity in living donors continues to be the most serious concern in the field, and we consider discussions of this aspect valuable towards strengthening our global collaboration as medical professionals to improve patient care. Full-Text PDF