Response to Letter “Systematic Grading of Morbidity After Living Donation for Liver Transplantation”
Article Outline
Dear Sir:
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 2008.1
We appreciate the comments by Tamura et al2 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.3 This grading system had been further utilized by Salvalaggio et al4 and Ghobrial et al5 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 2006.6
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 20047 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.
Acknowledgments
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
References
- Donor morbidity after living donation for liver transplantation. Gastroenterology. 2008;135:468–476
- Systematic grading of morbidity after living donation for liver transplantation. Letter to the editor. Gastroenterology. 2008;135:1804
- Definition and classification of negative outcomes in solid organ transplantation (Application in liver transplantation). Ann Surg. 1994;220:109–120
- Comparative analysis of live liver donation risk using a comprehensive grading system for severity. Transplantation. 2004;77:1765–1767
- Donor and recipient outcomes in right lobe adult living donor liver transplantation. Liver Transplant. 2002;8:901–909
- 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;81:1373–1385
- . Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213
Funding Supported in part by the National Institutes of Health (NIDDK grant numbers U01-DK62536, U01-DK62444, U01-DK62467, U01-DK62483, U01-DK62484, U01-DK62494, U01-DK62496, U01-DK62498, U01-DK62505, U01-DK62531), the American Society of Transplant Surgeons, and the U.S. Department of Health and Human Services, Health Resources and Services Administration.
Conflicts of interest The authors disclose no conflicts.
PII: S0016-5085(09)01563-7
doi:10.1053/j.gastro.2009.05.071
© 2009 AGA Institute. Published by Elsevier Inc. All rights reserved.
