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Liver and Liver Transplant Program Nutrition Guidelines

Liver and Liver Transplant Program

POLICY/PROCEDURE TITLE:
Nutrition protocol

DISTRIBUTE TO:
All supporting staff for the liver
program radiology, pathology

[ X] ADMINISTRATIVE [X ] CLINICAL
PAGE 1 OF 6

RELATED TO:

Effective Date:
Updated: NA

Revision Date: NA

[ x ] Patient Care

[ ] JCAHO

[x ] Nursing Practice

Unit/Service Line/Department of Origin:


[ ] Title 22 Liver and Liver Transplant Program

[ ] Med Ctr Policy (MCP) Stds [ ] QA


[ ] Other

[ ] UNOS

Other Approval: NA
Policy/Procedure
Completed

Committee Approval:

I. Obesity
Introduction
Obesity is a major medical problem, defined by a body mass index (BMI) of 30 kg/m 2 or
greater. Obesity may result in technical challenges to liver transplant surgery, increase
risk for wound dehiscence (1), increase infectious complications (2, 3), result in a longer
hospital stay (4), increased cost (5) and decreased survival following liver transplant (3,
5). The rate of primary liver graft nonfunction is also increased in patients with BMI >35
kg/m2 (5). Obesity is a recognized risk factor for multiple medical problems that may
significantly impact survival and quality of life in the liver transplant population. These
include diabetes, hyperlipidemia, cardiovascular disease, and cancer. Pre-transplant
obesity is an independent risk factor for development of metabolic syndrome following
liver transplant (6).
Classes of over weight and obesity defined by the World Health Organization:
BMI 25-30 kg/m2
overweight
BMI 30-35 kg/m2
obese
BMI 35-40 kg/m2
severely obese (morbid)
BMI >40 kg/m2
very severely obese (super morbid)
AASLD practice guidelines published in 2005 state that morbid obesity (defined in this
paper as BMI >40 kg/m2) should be considered a contraindication to liver transplant (7).

Assessment & Management of the Obese Patient in Liver Transplant Clinic


1. Obtain current height, weight and historical body weight and BMI should included
in each patients chart. Patient height needs to be measured by clinic staff
(patient report of height is not adequate).
2. Assess patients fluid status. Evaluate if the patient has fluid retention from
ascites and/or edema. Check abdominal ultrasound or cross sectional imaging
results to verify the presence of ascites or interstitial edema, if not readily
apparent from physical exam. Establish an estimated dry weight for the patient if
volume overloaded or use the patients current weight if no fluid retention is
present per physician assessment.
3. Calculate patients body mass index using estimated dry weight or current weight
(see above) and measured height without shoes
If the patients BMI is greater than 35 kg/m2, The patient will be asked to
sign a weight loss contract and the surgeon will help to determine if the
patient should be listed for transplant based upon the patients body
habitus and abdominal and rib structure and the transplant team will help
to assess obesity-related co-morbidities that may affect transplant
candidacy. Patients accepted for listing with a BMI greater than 35 kg/m2
will not be activated unless the team reaches a consensus on the
individual patients status or until the established goal weight is achieved
and maintained for 90 days.
i.
If at least 2 transplant surgeons agree that a patient with BMI
35-40 kg/m2 is transplantable based upon their body habitus
(and transplant candidacy is not otherwise affected by medical
co-morbidities via the hepatology team) then a patient may be
activated before weight loss occurs to reach BMI <35 kg/m2.
In these cases, patients will still be advised to work toward
achieving their goal weight while awaiting transplant.
1. These patients will be considered for combined LT and
vertical banded gastroplasty

If the patients BMI is greater than 40 kg/m2, or These patients will be


considered for combined LT and vertical banded gastroplasty
Or the patient will not be placed on the liver transplant waiting list. The
patient will be asked to sign a weight loss contract (see below) in order to
attain a goal weight deemed to be acceptable for reconsideration for
transplant candidacy. Once this goal weight is achieved, the patients case
will be re-discussed with the transplant selection committee.
i. Patients who have a BMI >40 kg/m2 with coronary artery
disease or significant diabetic nephropathy requiring a dual organ
transplant will not be considered as candidates for transplantation
at SJMC (8-10). These patients should be referred to an alternate
center for consideration for liver transplantation.

4. A goal weight will be established to achieve a BMI <35 kg/m2, and target a
healthy BMi in the 24-26 range (using a dry weight) will be advised for all patients
and each patients will be asked to sign a weight loss contract. The patient will be
asked to lose at least 20% of their excess weight within 6 months of signing

their weight contract to demonstrate compliance. The hepatologist and


registered dietician will monitor compliance at each visit. For example, a patient
weighing 250 lbs with a goal weight of 180 lbs (to achieve BMI <35 kg/m2) will
need to lose 14 lbs (250-180=70; 70 x 0.2 = 14) within 6 months to remain listed
for LT. Subsequently, patients will need to have lost a range of 30- 50% of
excess weight at 12 months to remain listed. Example: 250-180 = 70lbs; 70 x
0.5 = 35 lbs.

A weight contract will be signed by the patient at the time of their dietary
consultation
i.
This contract can consider <1200 calories per day due after an
assessment of risk of malnutrition is completed.
ii.
At least 1.2-1.5 gm/kg of protein intake per day is
recommended in the absence of concomitant renal disease.
i.
The contract will include expectations regarding exercise (see
below)

When the patient meets the established goal weight, the patient will be
activated for liver transplant.

If the patient is not able to meet weight loss goals, the patient will not be
considered a candidate for liver transplant. The patient will be informed
of their failure to meet their weight loss target (in person and in writing),
and will be removed from the liver transplant list after one year of
attempted weight loss.

Patients will be closely monitored by the liver transplant dietician, both in


clinic and by phone or secure Email messages between clinic visits, to
facilitate success with their dietary modification and ensure adequate
protein and caloric intake. Notes from outside dietician visits will be
scanned into the media section of the EHR so as to remain part of the
patients medical record.

5. In addition to meeting with the liver transplant dietician, a weight loss group, such
as Weight Watchers, Jenny Craig, Nutrisystem, or other acceptable weight loss
plan, may be recommended to patients in selected cases.

Any weight loss group or program is subject to review by the liver


transplant dietician in order ensure safety

6. The patient will be required to exercise and have a fitness plan tailored to their
medical condition. Recommendations should be 30 minutes of exercise at least
5 days per week.
If the patient has physical limitations that preclude exercise, then
referral to physical therapy will be strongly recommended.
7. Patients may be referred for bariatric surgery (vertical banded gastroplasty) if:

BMI >40 kg/m2 or 35 kg/m2 with associated comorbidity**


They have failed prior weight loss regimens
They are an acceptable surgical risk and Childs A cirrhosis.

Or at the time of LT if there is center that will accept the patient


i.
Patients will preferentially have bariatric surgery at a center
that is accustomed to operating on patients with cirrhosis.

**Coronary artery disease, type 2 diabetes, obstructive sleep apnea, obesity


hypoventillation syndrome, Pickwickian syndrome, NAFLD/NASH, hypertension,
dyslipidemia, pseudotumor cerebri, GERD, asthma, venous stasis disease, severe
urinary incontinence, debilitating arthritis, or considerable impaired quality of life From
AACE/TOS/ASMBS Guideline (11)

Weight Loss Contract


I understand that I am by calculated BMI, Body Mass Index (Website MedCalc)
Overweight: ______
BMI 25-29
Obese: _______
BMI 30-34
Morbidly obese: _______
BMI 35-39
Supermorbid obese: ______ BMI 40 +
I understand that I am at high risk of dying from: liver failure, cancer, liver
cancer, heart disease, kidney failure or stroke: ____________
I am committed to a stringent long-term goal of attaining a healthy weight:
_______________________ BMI target is 24 for Caucasians/other ethnic groups, BMI
target is 22 for Asians and Pacific Islanders
I hereby am committed to a weight loss program that works: _________
My Contract to lose weight includes:
1) Nutrition consult that I will arrange with my primary care provider
2) I will keep a Log book with within a paper folder or using
http://www.myfooddiary.com/ to record the following each day:
a. daily weights
b. daily calories counts
In addition: I will document
c. 3 hours of exercise per week
i. I will measure my heart rate with a target to be over 100
for 3 hours each week
ii. I will learn to take my heart rate or obtain and use a heart
rate monitor
3) I will Initiate an immediate 40 % calorie restriction
4) I will eat only 5 small meals per day of 150 to 200 calories each and I
will:
a. Use tea cup saucers for all meals, no second servings
b. Eat high protein, 80 100 gm per day
c. Consume moderate carbohydrate
d. Decrease to a American Heart Association low fat diet
5) I will not drink liquids from plastic bottles, and I will use only glass
storage containers (see information on bis-Phenols (BP) (see website:
Nova, keyword epigenetics), most plastics contain some form of BP
6) I will not drink alcohol
7) I will Utilize the Hungry is healthy motto
8) I will intake: Fiber supplements: 3 times per day with meals
9) I promise to return a Signed and dated weight contract
10) I will post the weight loss contract in my:
a. Bedroom
b. Bathroom
c. Kitchen
______________
___________________
____________________
Name
Signature
Date

II. Underweight Sarcopenia


Protocol for the Pre-Liver Transplant Underweight Patients
Protein energy malnutrition (PEM) is prevalent among patients with cirrhosis of all
etiologies. Even among those with compensated disease (Child class A), protein
depletion is reported approximately 20% of the time and among those with
decompensated disease, significant nutritional deficiencies are nearly universal. While
malnutrition is not captured in the MELD score, it is an independent predictor of poor
prognosis in cirrhosis and poor outcomes after liver transplant (12-15).
Definitions according to World Health Organization:
BMI <18.5 kg/m2
Underweight
BMI 17.00-18.49 kg/m2
Mild thinness
BMI 16.00-16.99 kg/m2
Moderate thinness
BMI < 16 kg/m2
Severe thinness
Causes of malnutrition in ESLD include the following (16):
1. Dietary insufficiency: anorexia, nausea, vomiting, early satiety, dysgeusia, and
unpalatable diet (sodium restriction)
2. Maldigestion/Malabsorption: exocrine pancreatic insufficiency, cholestasis, druginduced diarrhea (lactulose)
3. Altered metabolism: catabolic state in setting of infection, GI bleeding or other
acute illness, increased proinflammatory cytokines (TNF
glucose homeostasis
4. Iatrogenic: procedure-related prescribed fasting, repeated large volume
paracentesis
As important as nutritional status is in this patient population, nutritional assessment
faces particular challenges in advanced liver disease and there is currently no
universally accepted methodology. The subjective global assessment (SGA) (17) has
been validated in multiple patient populations and seems to perform reasonably well in
liver transplant candidates (15, 18), though requires a registered dietician or other
trained provider to perform. The most widely recognized anthropometric measure of
nutrition status, body mass index (BMI), may perform particularly poorly in cirrhotics due
to fluid retention (ascites and edema). It is possible, however, to utilize BMI in patients
with volume overload by estimating the amount of excess fluid (19). Other
anthropometric measures that may be informative, but are rarely performed, include
triceps skin fold thickness and mid-arm muscle circumference (see table for guidelines)
(16).
In addition to these tools, functional assessments may provide another means of
identifying patients at increased risk for poor outcome. Handgrip strength, using a
dynamometer, appears to be highly sensitive for PEM in patients with cirrhosis,
predictive of increased risk for complications in cirrhosis, and a marker of risk for longer
ICU stay and higher risk of infection after liver transplant (13, 20). Frailty is defined as
the biologic syndrome of decreased reserve and resistance to stressors, resulting from
cumulative declines across multiple physiologic systems, and causing vulnerability to
adverse outcomes (21). One aspect of frailty is muscle loss or sarcopenia. This was
evaluated among liver transplant candidates in a study performed at the University of
Michigan that measured psoas muscle area with CT scan and found strong association

between psoas area and post-transplantation mortality (hazard ratio=3.7/1,000mm2


decrease in psoas area; p<0.0001) (22). Gait speed (time, in seconds, to walk 5 meters)
has been reported to be an independent predictor or morbidity and mortality in elderly
patients undergoing cardiac surgery (23). Similar data for gait speed or ability to
ambulate 100 feet and liver transplant outcomes are not available in the published
literature at this time.

The major goals of pre-transplantation nutritional therapy are to first correct any macroand micro-nutrient deficiency and later to prevent further nutrient and protein depletion.
Nutrition support therapy should be inclusive of energy requirement (calories), protein
100 gms per day, vitamins, minerals, and trace elements. Patients with liver cirrhosis
exhibit early onset of gluconeogenesis after short-term fasting. Patients with portal
hypertension have documented fat malabsorption made worse by cholestasis. This
accelerated metabolic reaction to starvation may underlie their increased protein
requirements and muscle depletion. Provision of a nighttime feed (supplemental
nocturnal tube feeds) to patients with cirrhosis results in body protein accretion
equivalent to about 2 kg of lean tissue sustained over 12 months when compared to
patients supplemental during daytime hours (24). Energy and protein intake increased
similarly in both treatment groups thus it is hypothesized that by limiting the overnight
fasting period with a late-evening meal the progression to early onset of nocturnal
gluconeogenesis from amino acids is blunted with improvement in net nitrogen balance.

Perioperative
nutritional support with 14 days of parenteral nutrition in addition to oral diet has been
reported to reduce complications after major hepatectomy for hepatocellular carcinoma
associated with cirrhosis compared to patients receiving oral diet alone (25).

Assessment & Criteria of the Underweight/Sarcopenic Patient


1. Obtain current height, weight and historical body weight. Patient height needs to
be measured by clinic staff (patient report of height is not adequate).
2. Assess patients fluid status. Evaluate if the patient has fluid retention from
ascites and/or edema. Check abdominal ultrasound or cross sectional imaging
results to verify the presence of ascites if not readily apparent from physical
exam. Establish an estimated dry weight for the patient or use the patients
current weight if no fluid retention is present per physician assessment.
3. Nutrition assessment: calculation of BMI (kg/m2), handgrip strength, midarm
muscle circumference, prealbumin level, ability to walk 100 feet (30 meters) and
gait speed for 16 feet (5 meters)
a. If a patients BMI is <18.5 kg/m2, they will be considered malnourished.
The surgeon and hepatologist with the transplant selection committee
should decide if the patient may be activated for liver transplantation
based on their current nutritional status.
b. Patients who have BMI <18 kg/m2 should not be activated for transplant
until their nutritional status is improved to the extent that they are not felt
to be at significantly greater risk for adverse outcome secondary to
undernutrition. The primary modality of nutrition support to be
recommended is nocturnal tube feeds.
4. Patients identified as undernourished will need to sign a Nutrition Contract
a. They will have to show intake of recommended number of calories and
protein as required by the dietician.
b. The patient will enroll in an exercise program and/or physical therpay
c. They require close nutritional follow-up. This is primarily to be done by
the SJMC transplant dietician (both in clinic and between visits by phone
or MyChart communication). If an outside dietician is included in patient
management, records of these visits should be scanned into EPIC to be
included in the medical record.
d. If oral intake is inadequate by dietary recommendations, then patients will
be required to initiate tube feeds via NJ tube. Nocturnal tube feeds are
preferred based upon report of superior outcomes (24). 24 hour tube
feeds may be necessary to attain anabolic status.
e. Tube feeding may need to be continued after transplant if necessary
nutritional repletion has not occurred before that time.
f. Surgical J tubes and PEG tubes should be avoided due to the high risk of
complications.
g. Parenteral nutrition should only be used if the gut is not functioning
h. Lipids are strongly recommended in malnourished patients with portal
hypertension, especially those with hyperbilirubinemia due to the
presence of fat malabsorption.

III. Management Of Fat-Soluble Vitamin Deficiency In Cholestasis and Cirrhosis


Cholestatic liver disease includes a spectrum of disorders that produce retention of bile
acids and bilirubin (the predominant water soluble constituents in bile) in plasma and
microscopic evidence for biliary stasis. Changes in bile acid concentration are
associated with fat maldigestion from defective micelle formation. This results in
malabsorption of fat soluble vitamins and inefficient absorption of dietary fatty acids (26).

Vitamin D consists of 2 bioequivalent forms: D2 (ergocalciferol), obtained from vegetable


sources and supplements, and D3 (cholecalciferol), obtained from skin exposure to
UVB, oily fish, certain fortified foods, and supplements. Once absorbed, both are
metabolized in the liver to 25-hydroxyvitamin D (calcidiol) which is subsequently
converted to 1,25-dihydroxyvitamin D (calcitriol), primarily in the kidney (27, 28). Vitamin
D deficiency is extremely common in patients with chronic liver disease, many of whom
have severe deficiency (<7ng/ml) (29, 30). In mild to moderate liver dysfunction, vitamin
D malabsorption is the primary contributor to vitamin D deficiency. In severe liver
dysfunction, the liver is unable to produce 25-hydroxyvitamin D.
1. Monitoring Fat-Soluble Vitamins:
25-OH Vitamin D level (normal range > 30 mg/ml, 75 nmol/l){some data points to
ideal levels from 50 to 70)
(If renal disease, check 1,25-(OH)2 Vitamin D)
Vitamin A deficiency: diagnosed by clinical manifestation (xeroophthalmia) or
laboratory measure. Retinol level <20 mcg/dL or ratio of retinol:RBP <0.8
Serum carotene levels are also correlated with vitamin A and may be used as a
surrogate marker of malabsorption and malnutrition
Vitamin E level should be performed with concomitant fasting total lipid profile:
Effective serum vitamin E level = alpha-tocopherol (total cholesterol + triglycerides)
Ratio > 0.8 is normal; if < 0.6, supplement
Vitamin K: measure INR
2. Replacement of Fat Soluble Vitamins:
1. Vitamin D Deficiency
Vitamin D3 (cholecalciferol) is available in 400, 1,000, 5,000, and 50,000 unit
capsules., best dose for liver disease patients is 2000 units per day
Vitamin D2 (ergocalciferol) is available in 400 or 50,000 unit capsules and in a liquid
form (8,000 units/ml). Typical dose is 50 000 per week.
Some studies suggest that D3 is more efficient in repletion of vitamin D levels.

Patients who are deficient should be treated with 50,000 IU of vitamin D2 or D3


weekly for 8 weeks followed by 50,000 IU every 2 to 4 weeks or 800-1000 IU daily
thereafter. 25-hydroxyvitamin D levels should be monitored approximately 12 weeks
after initiation of therapy to assess for efficacy. Patients with significant
malabsorption may require higher doses of therapy (as much as 50,000 IU daily or
QOD until replete).
If a patient with severe malabsorption is unresponsive to a high dose therapy or if
there is co-existent renal failure (eGFR <30 mls/min), the patient should be switched
to the oral form of calcitriol (1,25-digydroxyvitamin D, Rocaltrol). Patients with severe
liver failure and thus decreased capacity to produce 25-hydroxyvitamin D from
vitamin D2 or D3 may also be placed on calcitriol so as to eliminate requirement for
this conversion. Calcitriol is available in 0.25 and 0.50 microgram capsules. If this is
poorly absorbed, then intravenous calcitriol may be administered.
The initial signs of vitamin D toxicity are hypercalciuria and hypercalcemia. Vitamin
D levels need to be followed monthly. Target blood levels of Vit D3 are 40-50.

2. Vitamin A Deficiency
Most patients with chronic liver disease obtain adequate vitamin A from a
multivitamin (RDA for adult males in 3000 IU and for adult females in 2300 IU).
Patients with cholestasis and deficiency may require 5,000-25,000 daily IU. Patients
on high dose supplements require monitoring for toxicity. Blood levels should be
checked every 6 months while on high dose therapy.
3. Vitamin E Deficiency:
Vitamin E deficiency is rare and may be manifest as neuromuscular disorders or
hemolysis.
Serum measurements of vitamin E are unreliable and so accurate levels require
concomitant measurement of fasting lipids. In individuals with fat malabsorption, 200
IU daily is usually sufficient to replace vitamin E in healthy people. Up to 800 units
per day may be used in CLD patients.

4. Vitamin K Deficiency:
Dietary vitamin K1 (phyloquinones) is found in green leafy vegetables (spinach, kale,
broccoli) while normal gut flora may synthesize vitamin K2 (menaquinone). Vitamin K
has a major role in the coagulation pathway and is also a cofactor for bone
mineralization. Risk factors for deficiency include poor dietary intake, cholestasis
with malabsorption, and chronic antibiotic use. Daily requirements are 90mcg for
women and 120mcg for men. Oral Vit K appears to have little or no effect on INR
levels due to lack of absorption combined with low efficiency of Vit K
activation.
If increased INR, attempt repletion with Vitamin K 10 mg SQ daily, for three days.
Parenteral vitamin K may be given monthly for maintenance, if required. This would

10

be most commonly done in patients with primary cholestatic liver disease (PBC or
PSC).

ADEK & AQUA ADEK


ADEK tablets and AQUA ADEK capsules are a convenient means of multi fat
soluble vitamin repletion, in a water miscible (micellar, more absorbable) formulation,
using single pills.
Practically, one AQUA ADEK pill would appear roughly equivalent to 2-3 ADEK pills.
Choose based upon severity of deficiency.

Vitamin K
Vitamin A
Vitamin E
Vitamin D

ADEK
150 mcg
5000 IU
50 IU
400 IU

AQUA ADEK capsules


700 mcg
18 000 IU
150 IU
800 IU

Information for SJMC


Pharmacy supplement cost:
Inpatient cost: ADEK chewable tablet = 26 cents/each
Oupatient cost: AquADEKs bottle of 60 capsules = $24.95

Other signs of micronutrient deificncy


Dermatitis (zinc, vitamin A, niacin)
Night blindness or photophobia (vitamin A)
Burning of mouth or tongue (B12 or folate)
Easy bruising (vitamin C or K)
Paresthesias (thiamine, pyridoxine)
Angular stomatitis (Vitamin B12, Vitamin B2, Vitamin B6)
Seborrheic dermatitis (Vitamin B2, Vitamin B6, Niacin)
Erythema or hyperpigmentation (niacin)

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References
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obese liver transplant recipients - a single Canadian Centre Experience. Ann Hepatol
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2.
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3.
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4.
Nair S, Cohen DB, Cohen MP, et al. Postoperative morbidity, mortality, costs,
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Selberg O, Bottcher J, Tusch G, et al. Identification of high- and low-risk patients
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Figueiredo F, Dickson ER, Pasha T, et al. Impact of nutritional status on
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Stickel F, Inderbitzin D, Candinas D. Role of nutrition in liver transplantation for
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17.
Detsky AS, Baker JP, Mendelson RA, et al. Evaluating the accuracy of nutritional
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JPEN J Parenter Enteral Nutr 1984;8:153-9.
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Hasse J, Strong S, Gorman MA, et al. Subjective global assessment: alternative
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Figueiredo FA, Dickson ER, Pasha TM, et al. Utility of standard nutritional
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Englesbe MJ, Patel SP, He K, et al. Sarcopenia and mortality after liver
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Afilalo J, Eisenberg MJ, Morin JF, et al. Gait speed as an incremental predictor of
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Arteh J, Narra S, Nair S. Prevalence of vitamin D deficiency in chronic liver
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13

Figure 1 demonstrating inferior survival following liver transplant in patients with BMI <
18.5 or 40 compared to those with pre-transplant BMI between 18.5 and < 40 (3).
Compared with the control group, the underweight patients had a higher
retransplantation rate due to graft failure and were more likely to die from hemorrhagic
complications or cerebrovascular accidents.
Analysis of Variables as Predictors of Risk to Survival During Period 3 (March 2002 to
2007; n=27,709 Patients). Shown are results of multivariable analysis

Variable

RR

Rank Order

Cryptogenic Cirrhosis
Retransplant
Tumor
BMI < 18.5
Hepatitis C
On life support at time of transplant
BMI 40
DCD Donor

3.71
1.76
1.74
1.73
1.52
1.44
1.41
1.36

<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
0.0005
<0.0001

1
2
3
4
5
6
7
8

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