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• W1977008001 abstract "Sheila Bird and colleagues correctly note that, although a diagnosis of hepatocellular carcinoma is a significant favourable prognostic factor for survival over the first 3 months after transplantation, it does not remain significantly associated with survival over the first year, suggesting that any possible beneficial effect in the first 3 months might be reversed with longer follow-up. We had not overlooked this fact, but due to lack of space, comment on it was omitted. The explanation is likely to lie in the fact that selection criteria for hepatocellular carcinoma in those with cirrhosis have varied in terms of tumour load. Many centres confine selection to either a single nodule of no more than 5 cm in diameter, or to three nodules or less, each no more than 3 cm in diameter on the basis of preoperative imaging.1Mazzaferro V Regalia E Doci R et al.Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis.N Engl J Med. 1996; 334: 693-699Crossref PubMed Scopus (5844) Google Scholar Moreover, these patients tend to have well preserved liver function, and are transplanted mainly for their tumour and not for deteriorating liver function. The latter makes them more likely to survive in the short term, but tumour recurrence means that their survival over the longer term might be poorer. Since most centres have now recognised this possibility, selection criteria for patients with hepatocellular carcinoma have become even more stringent, so recurrence rates are likely to decrease.2Grasso A, Stigliano R, Morisco F, et al. Liver transplantation and recurrent hepatocellular carcinoma: predictive value of nodule size in a retrospective and explant study. Transplantation (in press)Google Scholar Thus, the traditional “reversal” of the prognostic importance of a diagnosis of hepatocellular carcinoma might be less apparent in future analyses of this or other datasets. Although we would caution the use of our data to make inferences about survival between 3 and 12 months after transplantation (the patients included in the 3-month and 12-month analyses reported in tables 1 and 2 are not necessarily the same patients and thus the proportion of patients dying 3–12 months after transplantation cannot easily be determined from these), the second issue raised by Bird and colleagues is also important. A comparison of survival over 3–12 months among patients who survive for at least 3 months could provide useful information about outcomes over a period when the influences on outcome are more widespread. However, one of the main aims of our analyses was to provide clinicians with a prognostic tool that could be used at the time of transplantation to assess an individual's likely subsequent risk of mortality, thus allowing an informed decision about the possible outcomes of transplantation and the potential effects of doing transplants under different conditions (eg, with or without ABO matching). At the time of transplantation, whether the patient will survive for the first 3 months is not known, and analyses that are dependent on this knowledge are of limited use in this setting. Furthermore, any comparisons of outcomes across centres, which is based on patients having survived for at least 3 months, should also adjust for patients' characteristics at the 3-month timepoint (rather than only at the time of transplantation) which are likely to have changed over time. Unfortunately, this information is not collected as part of the European Liver Transplant Registry (ELTR) database and so we were unable to do these analyses. Lastly, we agree that as numbers accumulate in the ELTR, disease-related assessments will be important. In addition and perhaps more importantly, the interaction between the characteristics of donors and patients could reveal further insight into assessment of patients' outcomes after liver transplantation, and provide information about better allocation algorithms.3Cholongitas E, Marelli L, Shusang V, et al. The model for end stage liver disease (MELD): a systematic review of its performance in the setting of liver transplantation. Liver Transpl (in press).Google Scholar We declare that we have no conflict of interest. Analyse transplant outcomes in distinct epochs of follow-upAndrew Burroughs and colleagues (Jan 21, p 225)1 report country-unadjusted predictive models for 3-month and 12-month mortality after the first liver transplant in 1988–2003 for adults in Europe. No-names UK data were reported to the European Liver Transplant Registry (ELTR) by UK Transplant which, from the late 1980s, had recognised, and promoted, the importance of analysing transplant outcomes—kidney,2 liver,3 or heart4—in distinct epochs of follow-up. Full-Text PDF" @default.
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• W1977008001 date "2006-06-01" @default.
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• W1977008001 title "Analyse transplant outcomes in distinct epochs of follow-up – Authors' reply" @default.
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