Screening and care of patients with graft cirrhosis following liver transplantation

Introduction: Liver transplantation (LT) is vital for patients with end-stage cirrhosis, but survival is compromised by recurrent graft cirrhosis in 25% of recipients due to de novo or recurrent disease. This study aims to understand the trajectory, predisposing factors, and complications of graft cirrhosis to improve management in this patient population. Methods: We retrospectively reviewed 454 LT recipients diagnosed with graft cirrhosis from January 1, 1985, to December 31, 2019. We collected demographic, clinical, laboratory, imaging, endoscopic, and histological data. Statistical analysis was done with univariate and multivariate analyses. Results: Graft cirrhosis was frequently due to recurrent primary disease, with hepatitis C (49.2%) and graft rejection (9.6%) being primary contributors. Signs of decompensation, including primarily ascites, were seen in 12% of patients, with an 18% mortality rate at first decompensation. MELD-Na >15 was found in 62% of patients, driven by creatinine levels. Of note, 42% experienced portal hypertensive complications before deterioration in their synthetic function. Predictors of mortality included lower serum sodium, elevated aspartate transaminase, and older donor age. Only two patients developed de novo hepatocellular carcinoma (HCC). The Baveno VII criteria for varices needing treatment showed high sensitivity (100%) with moderate specificity (46.7%). Conclusions: Portal hypertensive complications often precede synthetic dysfunction in graft cirrhosis patients. Clinicians should screen for portal hypertensive complications, de novo HCC, and biochemical decompensation following graft cirrhosis. Early intervention can improve outcomes and prolong survival in LT recipients with graft cirrhosis.