australian national liver transplantation unit...there are several key issues to report. 1. a number...
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Australian National Liver Transplantation Unit
© copyright ANLTU Data to 31 December 2015
0
10
20
30
40
50
60
70
80
90
100
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Child (n = 306)Adult (n = 1256)
Data to 31 December 2015
Celebrating 30 years of Liver Transplantation
Data to 31/12/2015 © copyright ANLTU
Contents Preface ......................................................................................................................................... i Summary ..................................................................................................................................... ii ASSESSMENT INFORMATION ............................................................................................................................. 1 Allocation of Assessed Adults/Children ...................................................................................... 2 Patients Considered Unsuitable for Transplantation (Adults) .................................................... 2 Comparison Over Time Of Patients Assessed ............................................................................. 3 Waiting List Activity ..................................................................................................................... 4 Urgent Listings ............................................................................................................................ 5 Age and Waiting Time of Transplant Recipients (Primary Grafts) .............................................. 6 DONOR INFORMATION ...................................................................................................................................... 9 Deceased Donor Offers ............................................................................................................. 10 DBD Donor Offers...................................................................................................................... 14 DCD Donor Offers ...................................................................................................................... 14 Allocation of Accepted and Utilised Deceased Donor Offer Livers 2013 ................................. 15 Living Donor Procedures – Paediatric & Adult .......................................................................... 15 Deceased Donor Age by Era (Median) ...................................................................................... 16 Donors over 50 years ................................................................................................................ 16 Deceased Donor Cause of Death .............................................................................................. 17 RECIPIENT DEMOGRAPHICS ............................................................................................................................ 19 Patient Age at Transplant.......................................................................................................... 20 Primary Hepatic Disease ........................................................................................................... 20 Chronic Viral and Auto-Immune Hepatitis ................................................................................ 22 Fulminant Hepatic Failure as Primary Indication Treated by Liver Transplantation ................ 23 HCC and Associated Disease ..................................................................................................... 24 NASH/NAFLD by Era .................................................................................................................. 25 Indication For Secondary Transplantation ................................................................................ 26 PERIOPERATIVE DATA ...................................................................................................................................... 27 Mean/Median Hospital Stay ..................................................................................................... 28 Red Cell Usage ........................................................................................................................... 28 Graft Ischaemic Time, Operation Duration and Red Cell Utilisation ........................................ 28 OUTCOME DATA .............................................................................................................................................. 29 Patient Survival ......................................................................................................................... 30 Children ..................................................................................................................................... 32 Primary Disease and Outcome .................................................................................................. 34 Status at Transplant vs Patient Outcome ................................................................................. 35 Chronic HBV Outcomes ............................................................................................................. 36 Chronic HCV Outcomes ............................................................................................................. 37 Donor Age vs Primary Graft Outcome ...................................................................................... 40 Steatosis vs Graft Outcome (Adults) ......................................................................................... 41 Graft Survival ............................................................................................................................. 42 Split vs Reduced vs Whole Grafts ............................................................................................. 45 Cause of Death .......................................................................................................................... 47 Cause of Graft Failure ............................................................................................................... 52 CANCER AND TRANSPLANTATION ................................................................................................................... 57 Malignancy at Transplantation ................................................................................................. 58 De Novo Non Skin Cancer Post Transplant ............................................................................... 61 Pre Transplant Liver Disease and De Novo Non Skin Cancer .................................................... 62 Cumulative Risk of Diagnosis of Cancer .................................................................................... 64
Data to 31 December 2015 © copyright ANLTU
Data to 31 December 2015 © copyright ANLTU i
Preface
In 2015, 93 new, 4 secondary and 1 tertiary orthotopic liver transplant procedures were performed within the ANLTU (20 – The Children’s Hospital at Westmead; 78 – Royal Prince Alfred Hospital). This included the ongoing usage of split liver allografts and the use of extended criteria donor liver allografts, which maximise the limited donor resources available. The staff within the ANLTU would like to thank the members of the departments within Royal Prince Alfred Hospital and Sydney Local Health Network who have helped contribute to the success of the program in the past year. This includes Haematology, Biochemistry, other Laboratory services, Blood Bank, Department of Pathology, Department of Renal Medicine, Intensive Care Unit, Operating Room, Department of Psychiatry, Department of Cardiology, Department of Respiratory Medicine, Dietetic Department, Department of Social work, Department of Anaesthesia, the Casemix unit and all the other people who have not been specifically mentioned. We would also like to thank the other departments within the Children’s Hospital at Westmead, who have helped contribute to the success of the paediatric programme. These include the membership of Department of Anaesthesia, the Intensive Care Unit, Laboratory services staff, Department of Social Work, Department of Nutrition and other medical departments. The staff of the Australian Red Cross Blood Service are also acknowledged for their assistance during the year. Finally, without the generosity of the deceased organ donors and their families, liver transplantation would not be able to proceed at this level. Hence we give our thanks to them as well as to the team at Donate Life NSW, Kogarah. Professor Geoff McCaughan Dr Deborah Verran Dr Michael Crawford Pamela Dilworth Gavin Lackey
Data to 31 December 2015 © copyright ANLTU ii
Data to 31 December 2015 © copyright ANLTU iii
Summary
Summary There are several key issues to report.
1. A number of new heights were reached in 2015. These were:
98 orthotopic liver transplant procedures 122 new listings on the Waiting List 68 patients on the Waiting List at the end of the year 8 Donations after Circulatory Death 10 Paediatric Donors
2. In 2015, 93 new, 4 secondary and 1 tertiary orthotopic liver transplant procedures were performed, 20 of which were Paediatric and 78 were Adult.
3. Between January 1986 to December 2015, 1562 liver transplants were performed on 1444 patients, of which 1179 and 265 recipients were adults and children, respectively.
4. The number of transplants per year continues to be related to the deceased donor rate.
5. In 2015, 19 patients (10%) on the waiting list were subsequently withdrawn due to advanced and/or extra-hepatic disease. One patient improved whilst on the waiting list.
6. The movement of patients on and off the waiting list continues to be dynamic.
7. The average waiting time for adults in all blood groups remains variable depending on blood group.
8. The median deceased donor age has increased from 29 years (1986 – 1995) to 44 years (2006 – 2016). In 2015 there were ten deceased donors over the age of 70 years. This is the highest number of donors from this age group whose livers have been used for transplant.
9. The median age for adult recipients has increased from 45.7 years (1986 – 1995) to now stand at 49.5 years. The median age for child recipients has decreased from 4.1 years (1986 – 1995) and now stands at 2.2 years.
10. HCV infection has been an increasing primary and secondary indication for liver transplantation in adults. In the period 1986 – 1995 11% of adults had this diagnosis compared to 37% in 2006 – 2015.
11. Hepatocellular carcinoma has also become an increasingly common primary and secondary indication for liver transplantation, with 28% of the adult recipients having a diagnosis of HCC in the five year period 2011 – 2015.
12. The overall patient survival rate over the past 2 years was 93% at one year.
Data to 31 December 2015 © copyright ANLTU
Data to 31 December 2015 © copyright ANLTU 1
ASSESSMENT INFORMATION
Data to 31 December 2015 © copyright ANLTU 2
Assessment Information
Allocation of Assessed Adults/Children
© copyright ANLTU Data to 31 December 2015
Allocation of Patients Accepted for Assessment
Accepted67%
Deferred11%
Unsuitable20% Died Pre-
List2%
Adults (n = 2375)
Accepted88%
Deferred5%
Unsuitable7%
Children (n = 350)
Patients Considered Unsuitable for Transplantation (Adults)
© copyright ANLTU Data to 31 December 2015
Patients Considered Unsuitable for Transplantation2375 Adults have been assessed since 1985
Reason Adults
Too Advanced + extra-hepatic disease 173 37%
Tumour Progression + Tumour (extra-hepatic spread) 76 16%
Good prognosis 64 14%
Psychological 59 13%
Alcohol 57 12%
Patient’s wish 24 5%
Alternative therapy 7 1%
Age 5 1%
Condition improved 2 <1%
Logistics 1 <1%
Total 468 100%
Data to 31 December 2015 © copyright ANLTU 3
Assessment Information
Comparison Over Time Of Patients Assessed
Comparison Over Time of Patients Assessed
© copyright ANLTU Data to 31 December 2015
1985 - 1995
Accepted48%
Deferred18%
Unsuitable34% Died
Pre-List
0.2%
Adults (n = 657)
Accepted72%
Deferred11%
Unsuitable17%
Children (n = 120)
© copyright ANLTU Data to 31 December 2015
1996 - 2005
Accepted62%
Deferred16%
Unsuitable20%
Died Pre-List2%
Adults (n = 918)
Accepted94%
Deferred3%
Unsuitable3%
Children (n = 112)
© copyright ANLTU Data to 31 December 2015
2006 - 2015
Accepted89%
Deferred1%
Unsuitable7%Died Pre-
List3%
Adults (n = 800)
Accepted98%
Unsuitable2%
Children (n = 118)
Adult patient acceptance rate has increased from 48% in the period of 1985 – 1995 to 89% in 2006 – 2016. Child patient acceptance rate has increased from 72% in the period of 1985 – 1995 to 98% in 2006 – 2015.
Data to 31 December 2015 © copyright ANLTU 4
Assessment Information
Waiting List Activity
© copyright ANLTU Data to 31 December 2015
Waiting List Activity
YearListed at Start of
Year
New Listings Total Tx Died
Pre Tx
Withdrawn Total Withdrawn/
MortalityImproved Listed at
End of YearTumour Progressed Other
2006n 38 83 121 55 6 3 0 9 6 46
% 45 5 2.5 0 7.4 5
2007n 46 95 141 54 19 2 2 23 2 63
% 38 13 1 1 16 1
2008n 63 76 139 59 25 2 5 32 5 43
% 42 18 1 3.5 23 3.5
2009n 43 97 140 59 11 3 5 19 8 54
% 42 8 2 3.5 13.6 5.7
2010n 54 98 152 77 6 4 2 12 2 61
% 51 4 3 1 8 1
2011n 61 82 143 71 9 5 2 16 4 52
% 50 6 3 1 11 3
2012n 52 104 156 75 15 2 9 26 2 53
% 48 10 1.3 6 17 1.3
2013n 53 113 166 80 15 5 11 31 3 52
% 48 9 3 7 19 2
2014n 52 112 164 76 5 1 14 20 4 64
% 46 3 0.6 9 12 2
2015n 64 122 186 98 3 3 13 19 1 68
% 53 2 2 7 10 .5
© copyright ANLTU Data to 31 December 2015
46
63
43
54
61
52
53
52
64
68
0 10 20 30 40 50 60 70 80
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Patients on Waiting List at the end of Calendar Year
Data to 31 December 2015 © copyright ANLTU 5
Assessment Information
© copyright ANLTU Data to 31 December 2015
7.4
16
23
14
811
1719
1210
5
1
3.5
6
1
3
1
2
2
0.5
0
5
10
15
20
25
30
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Improved
Withdrawn/Mortality
% Patients Withdrawn from Waiting List
Urgent Listings
© copyright ANLTU Data to 31 December 2015
Urgent Listings 2015
Number of Patients Listed as Urgent Cat 1 Cat 2 Total
Transplanted 6 6 12
Delisted 0 0 0
Total 6 6 12
Data to 31 December 2015 © copyright ANLTU 6
Assessment Information
Age and Waiting Time of Transplant Recipients (Primary Grafts)
© copyright ANLTU Data to 31 December 2015
2030
4050
6070
Age
at T
rans
plan
t - Y
ears
1986 - 1995 1996 - 2005 2006 - 2015
05
1015
Age
at T
rans
plan
t - Y
ears
1986 - 1995 1996 - 2005 2006 - 2015
Age of Transplant Recipients (Primary Grafts)
n 63 89 113
Median 4.1 2.4 1.4
Mean 5.6 4.3 3.4
Children
n 265
Median 2.2 years
Mean 4.2 years
Range 0.1 – 15.6 years
n 244 397 538
Median 45.7 50.5 54.2
Mean 44.0 49.1 52.3
Adults
n 1179
Median 51.9 years
Mean 49.5 years
Range 16.1 – 69.5 years
© copyright ANLTU Data to 31 December 2015
Waiting Time of Transplant Recipients (Primary Grafts)Children
Median 2.33 months
Mean 5.15 months
Max 76.49 months
Adults
Median 2.39 months
Mean 5.52 months
Max 95.48 months
Median 1.54 3.11 2.33
Mean 2.91 6.48 5.48
Max 14.49 48.10 76.49
Median 0.79 2.16 4.30
Mean 1.27 4.46 7.91
Max 7.84 69.25 95.48
05
1015
2025
Mon
ths
Wai
ting
1986 - 1995 1996 - 2005 2006 - 2015
05
1015
20M
onth
s W
aitin
g
1986 - 1995 1996 - 2005 2006 - 2015
Data to 31 December 2015 © copyright ANLTU 7
Assessment Information
© copyright ANLTU Data to 31 December 2015
5.5
98.6
3.6
1.5
4
9.7
12.7
6.9
11.7
6.67.3
0
2
4
6
8
10
12
14
2007 - 2009 2010 - 2012 2013 - 2015
AABBO
Adult Mean Months WaitingPrimary Liver Transplantation vs ABO (2007 – 2015)
© copyright ANLTU Data to 31 December 2015
2007– 2009 2010 – 2012 2013 – 2015 Overall
A 5.5 9 8.6 8.2
AB 3.6 1.5 4.0 3.2
B 9.7 12.7 6.9 9.6
O 11.7 6.6 7.3 8.3
Mean 8.7 8.4 7.6 8.2
Adult Mean Months WaitingPrimary Liver Transplantation vs ABO (2007 – 2015)
Data to 31 December 2015 © copyright ANLTU 8
Assessment Information
Data to 31 December 2015 © copyright ANLTU 9
DONOR INFORMATION
Data to 31 December 2015 © copyright ANLTU 10
Donor Information
Deceased Donor Offers
© copyright ANLTU Data to 31 December 2015
53
46
52 51
66
61
69
74
69
79
14
2 3 4 42 2 2
10
1 2 3 4 52 3
58
0
10
20
30
40
50
60
70
80
90
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Adult DBD Paediatric DBD Adult DCD
Deceased Adult and Paediatric Donor Organs Used By Year
Since 2000, 93.7% of liver donors were adults (>=15yrs) and 6.3% were paediatric donors.
© copyright ANLTU Data to 31 December 2015
Deceased Donor Offers to NSW 2007 - 2015Donor Type State 2007 - 2009 2010 - 2012 2013 2014 2015 Total
DBD
ACT 12 20 5 9 10 56
NSW 147 194 88 63 89 581
NT 3 2 1 1 1 8
NZ 9 10 1 5 6 31
QLD 23 18 5 7 12 65
SA 15 9 7 5 9 45
TAS 4 1 1 1 7
VIC 19 32 7 3 10 71
WA 8 15 6 8 4 41
Total BDD Offers 240 303 121 102 141 907
BDD Used 137 186 68 66 83 540
DCD
ACT 6 6 1 3 16
NSW 41 66 15 15 19 156
NT 1 1
NZ 1 1
QLD 1 1 2
SA 1 1
VIC 1 7 1 3 2 14
WA 1 1
Total DCD Offers 48 81 17 20 26 192
DCD Used 7 15 3 5 8 38
Total Offers 288 384 138 122 167 1099
Total Used 144 201 71 71 92 579
Data to 31 December 2015 © copyright ANLTU 11
Donor Information
© copyright ANLTU Data to 31 December 2015
DBD Donor Offers Declined 201558/143 (40.6%)
Declined at Offer
Declined at Hepatectomy
Abnormal LFTs 3
Cirrhosis 1
Consent withdrawn/relatives refused consent 1
Donor Age 1
Donor history * 5
Donor malignancy - extrahepatic 1
High risk donor for tumour or infection 5 2
Impaired perfusion/ischaemia 2
Interstate donor not suitable for directed recipient (Urgent Case) 7
Liver fibrosis 2
Logistics ** 1
No suitable ABO compatible recipient/No suitable recipient 7
Offer waived for urgent Tx elsewhere/Offer waived *** 6 1
Positive virology 1
Steatosis 6
Trauma to liver/Vascular issues 1 1
Other **** 1 3
TOTAL 40 18
© copyright ANLTU Data to 31 December 2015
DBD Donor Offers Declined 201558/143 (40.6%)
* Donor history 1 Alpha 1 anti-trypsin. No patients with high enough MELD to accept risk of transmission.
Declined all states
2 Heavy ETOH/Tumour Risk (underweight/heavy smoker/hx coughing up blood/strong FHxcolorectal cancer)/Infections inadequately treated.
3 Likely fatty liver in combination with high strength inotropes, elevated INR, abnormal LFTs and high risk of infection transmission.
4 Multiple reasons: age, obesity, diabetes. Hypertension, smoker
5 Vascular disease, age, obesity (BMI 41), prostate ca
** Logisitcs 1 Long CIT from WA, already cross clamped.
*** Offer waived 1 Accepted for a Cat 1 pt, however local donor became available at same time. Hepatectomy
proceeded and sent to another interstate urgent listing.
**** Other 1 Biliary abnormality on cholangiogram. Unable to split..
2 Gangrenous gallbladder extending into hilum.
3 Liver & kidneys retrieved however heparin not given. Team decided not to proceed. No other organs retrieved.
4 Offer revoked. Local team accepted offer. Were enquiring if we were interested if NAT positive
Data to 31 December 2015 © copyright ANLTU 12
Donor Information
© copyright ANLTU Data to 31 December 2015
DCD Donor Offers Declined 201518/26 (69.2%)
Declined at Offer
Declined at Hepatectomy
Abnormal LFTs 1
DCD did not proceed to hepatectomy 10
Donor history * 1
Impaired perfusion/ischaemia 2
Interstate donor not suitable for directed recipient (Urgent case) 1
Offer waived for urgent Tx elsewhere 1
Steatosis 1
Unstable
Other ** 1
TOTAL 5 13
* Donor history 1 Obese in a DCD, Hx Prader Willi Syndrome. Attempted kidney retrieval - did not die in time frame.
** Other 1 Long CIT in DCD
Data to 31 December 2015 © copyright ANLTU 13
Donor Information
© copyright ANLTU Data to 31 December 2015
Enquiries Declined 2015
Declined at Enquiry
Abnormal LFTs 1
Consent withdraw/relatives refused consent 3
Donor age 7
Donor arrest prior to retrieval 1
Donor history * 8
High risk donor for tumour or infection 10
Interstate donor not suitable for directed recipient (Urgent Case) 3
Known liver disease ** 2
Logistics 1
No suitable recipient 3
No suitable ABO compatible recipient 7
Outside DCD acceptance criteria 4
Other *** 5
TOTAL 55
© copyright ANLTU Data to 31 December 2015
Enquiries Declined 2015* Donor
history 1 ? Cause of encephalitis.
2 DCD, downtime, ?hepatorenal, ECMO, CVVHD, DIC, metabolic acidosis, diabetes, cardiovascdisease, bili 235.
3 DCD, unstable donor, complicated admission, extensive medical hx, HCV, ? Current IVDU.
4 Donor Age, comorbidities, poor vessels, smoker, inotropes.
5 ESRF, dialysis, CAGS, bilat common iliac artery stents, BMI 42, hx deranged LFT's.
6 Extensive peripheral vascular disease.
7 Infective Endocarditis. Extensive cardiovascular hx, on dialysis. Will be a DCD.
8 Long cardiac downtime with abnormal INR, likely ischaemic damage. Requiring high dose inotropes, unable to be supported
** Known liver disease 1 Cirrhosis, extensive vascular disease, endovascular stent leak.
2 DCD, HCV, chronic liver disease, IVDU, bili 573, abnormal blood results. Extensive medical issues this admission.
*** Other 1 Asked DonateLife to pursue donor. Later informed that treatment had been withdrawn.
2 Did not proceed to formal offer. Deemed NMS as organ donor as no COD determined
3 Hx of ETOH abuse, drug use. Accepted enquiry however did not proceed to formal offer. Pt died before offer
4 Never proceeded to formal offer
5 Said to pursue donor. Never progressed to full referral
Data to 31 December 2015 © copyright ANLTU 14
Donor Information
DBD Donor Offers
© copyright ANLTU Data to 31 December 2015
42
47 48
6062
6468
66
83
911
912 11
20
25
1618
21
30
2325 26
23
28
20
40
0
10
20
30
40
50
60
70
80
90
2007 2008 2009 2010 2011 2012 2013 2014 2015
Used Declined at Hepatectomy Declined at Offer
DBD Donor Offers to NSW
DCD Donor Offers
© copyright ANLTU Data to 31 December 2015
1
2
4
8
5
2
3
5
8
6
8
10
5
9
7
8
13
5
8
11
18
9
15
7
6
5
0
2
4
6
8
10
12
14
16
18
20
2007 2008 2009 2010 2011 2012 2013 2014 2015
Used Declined at Hepatectomy Declined at Offer
DCD Donor Offers to NSW
Data to 31 December 2015 © copyright ANLTU 15
Donor Information
Allocation of Accepted and Utilised Deceased Donor Offer Livers 2013
© copyright ANLTU Data to 31 December 2015
Allocation of Accepted and Utilised Deceased Donor Livers
1st Recipient Allocation Total
DBD
Highest prioritised patient suitable for this type of graft 69
Size of graft not suitable for higher priority patient(s) 6
Higher priority patient(s) medically unfit 2
Higher priority patient(s) has HCV and older donor 1
Logistical reasons not suitable for higher priority patients 1
No prioritised patient in this ABO suitable 1
No prioritised patient in this ABO suitable for Split Graft 1
Positive donor virology 1
Other * 2
DCDHighest prioritised patient suitable for this type of graft 7
High risk donor on history for virus or tumour 1
Total 92
2nd Recipient Allocation
DBD Highest prioritised patient suitable for this type of graft 5
Total 5
* Other Required combined liver/lung tx
Suitable graft for this patient
Living Donor Procedures – Paediatric & Adult
© copyright ANLTU Data to 31 December 2015
Living Donor Procedures – Paediatric and Adult
* The Living Unrelated Donor Procedures in 2003 and 2013 were adult domino transplants.
** The Living Unrelated Donor Procedure in 2011 was adult to adult.
Year 1990 2002 2003 2004 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Total
TypeLRD LRD LUD
*LRD LRD LRD LRD LRD LRD LUD
**LRD LUD
*LRD
Total 1 1 1 1 2 3 3 2 3 1 2 1 0 1 22
Data to 31 December 2015 © copyright ANLTU 16
Donor Information
Deceased Donor Age by Era (Median)
© copyright ANLTU Data to 31 December 2015
020
4060
80D
onor
Age
- Ye
ars
1986 - 1995 1996 - 2005 2006 - 2015
Deceased Donor Age by Era
n 336 518 686
Median 29 42 44
Mean 31.1 38.7 43.2
n = 1540
Median 40 years
Mean 39.1 years
Range 0.01 – 87.0 years
The donor age ranged from 0 to 87 years, with a mean value of 40 years.
Donors over 50 years
© copyright ANLTU Data to 31 December 2015
1 2 1 15
810
3 4 57
9 96
84
7
18
118 8
14
9 1012
17
10
1517
1
4
3
13 1
3
86
32
4
4
6
8
5 5
7
9 7
13
13
11
9
14
2
22
3
5
2
51
26
4
3
7
8
7
1
1
21
3
0
5
10
15
20
25
30
35
40
45
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
> 80 (n = 8)71 - 80 (n = 59)61 - 70 (n = 150)51 - 60 (n = 239)
Deceased Donors Over 50 Years(n = 456)
Data to 31 December 2015 © copyright ANLTU 17
Donor Information
Deceased Donor Cause of Death
© copyright ANLTU Data to 31 December 2015
Hypoxia/Anoxia15%
Cerebrovascular Accident
49%
Tumour1%
Road Trauma23%
Other Trauma9%
Other2% Suicide
1%
Hypoxia/AnoxiaCerebrovascular AccidentTumourRoad TraumaOther TraumaOtherSuicide
Deceased Donor Cause of Death(n = 1540)
754 (49%) donors died due to cerebral haemorrhage, 495 (32%) died due to trauma.
© copyright ANLTU Data to 31 December 2015
32
46
151
147
282
325
4
6
5
115
137
106
36
35
66
1
5
6
1
7
27
0 50 100 150 200 250 300 350
1986 - 1995
1996 - 2005
2006 - 2015
OtherSuicideOther TraumaRoad TraumaTumourCerebrovascular AccidentHypoxia/Anoxia
Deceased Donor Cause of Death by Era
Deaths due to trauma were 45% (1986 – 1995), 42% (1996 – 2005) and 25% (2006 – 2015). In these same time periods, deaths due to cerebral causes were 44%, 54% and 47%.
Data to 31 December 2015 © copyright ANLTU 18
Donor Information
© copyright ANLTU Data to 31 December 2015
16
7
2321
33
46
40
48
40
52
20 20
17
1315
1112 12
21
18
23
6
10
56
3 32
46
2
7
21 1 1
0
5
10
15
20
25
30
35
40
45
50
55
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
S0 (n = 326) S1 (n = 159)S2 (n = 40)S3 (n = 24)
Adult Graft Steatosis 2006 - 2015
Steatosis Scoring: S0 less than 5% steatosis in biopsy (either macro or micro) S1 Ma/Mi 5 – 29% Macrovesicular steatosis on biopsy combined with varying degrees of Micro S2 Ma/Mi 30 < 60% Macrovesicular steatosis on biopsy combined with varying degrees of Micro S3 Ma/Mi 60 +% Macrovesicular steatosis on biopsy combined with varying degrees of Micro Since 2006 there are 18 cases (3.2%) where post reperfusion biopsy was not performed.
Data to 31 December 2015 © copyright ANLTU 19
RECIPIENT DEMOGRAPHICS
Data to 31 December 2015 © copyright ANLTU 20
Recipient Demographics
Patient Age at Transplant
© copyright ANLTU Data to 31 December 2015
79 71
109
213
292
490
149
41
0
50
100
150
200
250
300
350
400
450
500
< 1 1 - 3 4 - 15 16 - 40 41 - 50 51 - 60 61 - 65 > 65
Breakdown of Patient Age at Primary Transplant(n = 1444)
The modal group was in the age range 51 – 60 years (33.9%).
Primary Hepatic Disease
© copyright ANLTU Data to 31 December 2015
Biliary Atresia11%
Malignancy9%
HCV19%Metabolic
9%
Fulminant10%
ALD10%
CC2%
PSC8%
PBC5%
Other4%
AIH4%
HBV6%
B,C1%
NASH/NAFLD2%
Primary Disease – All Patients(n = 1444)
The most common primary indications for transplantation are Chronic Hepatitis C (270, 19%), Biliary Atresia (154, 11%), Alcoholic Disease (146, 10%) and Fulminant Liver Failure (143, 10%).
Data to 31 December 2015 © copyright ANLTU 21
Recipient Demographics
© copyright ANLTU Data to 31 December 2015
Biliary Atresia1%
Malignancy11%
HCV23%
Metabolic6%
Fulminant10%
ALD12%
CC2%
PSC10%
PBC6%
Other4%
AIH4% HBV
7%B,C1% NASH/NAFLD
3%
Primary Disease – Adults(n = 1179)
Hepatitis C was the most common indication of transplantation in adults (270, 23%), followed by Alcoholic Liver Disease (ALD 146, 12%), Malignancy (129, 11%), Primary Sclerosing Cholangitis (PSC 119, 10%), Fulminant Hepatic Failure (114, 10%), and Hepatitis B (83, 7%).
© copyright ANLTU Data to 31 December 2015
Biliary Atresia54%
Malignancy3%
Metabolic23%
Fulminant11% CC
1%CAH2%
Other7%
Primary Disease – Children(n = 265)
The most common indication for transplantation in children was Biliary Atresia (143, 54%), followed by Metabolic disease (60, 23%) and Fulminant Hepatic Failure (29, 11%).
Data to 31 December 2015 © copyright ANLTU 22
Recipient Demographics
Chronic Viral and Auto-Immune Hepatitis
© copyright ANLTU Data to 31 December 2015
Chronic Viral and Auto-Immune HepatitisPrimary and Secondary
n = 549 (46.6% of all Adults)
AIH9% B, C
2%
HCV63%
HBV23%
HDV3%
Viral91%
Auto-Immune Hepatitis (AIH) comprised 9% of cases, the remainder (91%) being viral in origin (CVH). Of the cases of viral hepatitis, the most common is Hepatitis C (HCV, 63%), followed by Hepatitis B (HBV, 23%) HDV (3%) and HBV/HCV co-infection (2%).
© copyright ANLTU Data to 31 December 2015
Chronic Viral (Primary and Secondary)Adults by Era
11%11%
78%
1986 - 1995
9%
37%54%
2006 - 2015
HBV (n = 128)
HCV (n = 345)
Non Viral (n = 706)
14%
30%56%
1996 - 2005
The number of patients requiring transplantation due to HCV has steadily increased over the three time periods, whereas the number of patients requiring transplantation for HBV has now decreased.
Data to 31 December 2015 © copyright ANLTU 23
Recipient Demographics
© copyright ANLTU Data to 31 December 2015
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1986 - 1995 1996 - 2005 2006 - 2013 2014 2015
Non Viral (n = 706) HBV (n = 128) HCV (n = 345)
% Adults with Chronic HBV or HCV(Primary and Secondary)
Chronic HCV infection comprises 22.9% of adults transplanted.
Fulminant Hepatic Failure as Primary Indication Treated by Liver Transplantation
© copyright ANLTU Data to 31 December 2015
Fulminant Hepatic Failure As Primary Indication Treated by Liver Transplantation
Aetiology No of Patients No of TxOutcome
Alive Dead
Idiopathic 53 58 34 19
Drug Induced 22 24 14 8
Wilson’s Disease 14 16 12 2
Viral Hepatitis
Hep B 32 33 19 13
Hep C 1 1 1 0
Hep A 3 3 0 3
Hep E 1 1 0 1
Autoimmune Hepatitis 5 6 3 2
Budd-Chiari 1 1 0 1
Other 11 12 9 2
Totals 143 155 92 (64% pts) 51 (36% pts)
Data to 31 December 2015 © copyright ANLTU 24
Recipient Demographics
HCC and Associated Disease
© copyright ANLTU Data to 31 December 2015
HCC AND Associated DiseaseAdults by Era
HBV34%
HCV33%
Other33%
1986 - 1995
* HCV includes 1 case of HBV,HCV
NASH/NAFLD
7%
HBV40%
HCV *37%
Alcholic Cirrhosis
13%
Other10%
1996 - 2005
* HCV includes 2 case of HBV,HCV
© copyright ANLTU Data to 31 December 2015
HCC and Associated DiseaseAdults by Era
NASH/NAFLD
6%
HBV *22%
HCV50%
Alcoholic Cirrhosis
20%
Other4%
2006 - 2010
* HBV includes 1 case of HDV
HCC Only1%
NASH/NAFLD
7%
HBV *12%
HCV **42%
Alcholic Cirrhosis
28%
Other10%
2011 - 2015
* HBV includes 2 cases of HDV** HCV includes 1 case of HBV,HCV
Data to 31 December 2015 © copyright ANLTU 25
Recipient Demographics
NASH/NAFLD by Era
© copyright ANLTU Data to 31 December 2015
NASH/NAFLD (Primary and Secondary)Adults by Era
NASH/NAFLD
2%
Other98%
1996 - 2005
NASH/NAFLD
0%
Other100%
1986 - 1995
© copyright ANLTU Data to 31 December 2015
NASH/NAFLD (Primary and Secondary)Adults by Era
NASH/NAFLD
5%
Other
2006 - 2010
NASH/NAFLD
10%
Other
2011 - 2015
Data to 31 December 2015 © copyright ANLTU 26
Recipient Demographics
Indication For Secondary Transplantation
© copyright ANLTU Data to 31 December 2015
1
7
13
37
21
5
3
5
511
15
21
2
5
81
4
4
11
1 1
2
4
0
5
10
15
20
25
30
35
0 - 7 days 8 - 30 days 1 - 6 months 6 months - 1 year
1 - 5 years > 5 years
Time to Secondary Transplant
OtherBiliary StricturesViral RecurrencePNFRejectionVascular
Indication for Secondary Transplantation(n = 125)
Primary non function (PNF) is the major indication for re-transplantation in the first 7 days. Rejection and vascular indications are prominent indications for re-transplantation in all other time periods.
© copyright ANLTU Data to 31 December 2015
57.1%
48.6% 48.5%51.0%
60.4%
55.6%
0%
10%
20%
30%
40%
50%
60%
70%
1986 - 1990 1991 - 1995 1996 - 2000 2001 - 2005 2006 - 2010 2011 - 2015
Percentage of Children Transplanted for Biliary Atresia(n = 143; 54.0% of all Children)
Data to 31 December 2015 © copyright ANLTU 27
PERIOPERATIVE DATA
Data to 31 December 2015 © copyright ANLTU 28
Perioperative Data
Mean/Median Hospital Stay
© copyright ANLTU Data to 31 December 2015
9
5 56
53
43 3
5 5
23 3 3
4 4 46
4
86
46
76
8
5 56
36
32
44
49
42
32
38
24 24
40
26
32
42
25 2526
24
21
18
23
20
15
1918
1618
17
13
16
12
0
5
10
15
20
25
30
35
40
45
50
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
ICU (Mean)Ward (Mean)ICU (Median)Ward (Median)
Hospital Stay (Mean & Median Days)Adults Only
Red Cell Usage
© copyright ANLTU Data to 31 December 2015
133 133
58
1611
4
0
20
40
60
80
100
120
140
1986 - 1995 1996 - 2005 2006 - 2015
Red Cell Usage (Max)
Red Cell Usage (Median)
Red Cell Usage(Units of Packed Cells)
Graft Ischaemic Time, Operation Duration and Red Cell Utilisation
© copyright ANLTU Data to 31 December 2015
Graft Ischaemic Time, Operation DurationAnd Red Cell Utilisation
1986 – 1995 1996 – 2005 2006 – 2015
Mean Graft Ischaemic Time 9 hr 18 min 9 hr 11 min 8 hr 20 min
Mean Operation Time 7 hr 43 min 7 hr 23 min 7 hr 13 min
No. Of Packed Cells Utilised1 – 133
Mean = 20.8; Median = 16
0 – 133 Mean = 14.6;Median = 11
0 – 58 Mean = 6.3;Median = 4
Data to 31 December 2015 © copyright ANLTU 29
OUTCOME DATA
Data to 31 December 2015 © copyright ANLTU 30
Outcome Data
Patient Survival
© copyright ANLTU Data to 31 December 2015
025
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100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Overall Patient Survival 1986 - 2015Adults and Children
1yr 5yr 10yr 15yr 20yr 25yr
No at risk 1181 817 528 285 139 44
Actuarial Survival % 88 79 70 61 52 45
n = 1444
© copyright ANLTU Data to 31 December 2015
025
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100
% S
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ving
0 6 1812 24Months Post Transplant
Patient Survival 2014 - 2015Adults and Children
6m 12m 18m
No at risk 114 67 30
Actuarial Survival % 97 93 92
n = 166
Data to 31 December 2015 © copyright ANLTU 31
Outcome Data
© copyright ANLTU Data to 31 December 2015
025
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% S
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ving
0 5 10 15 20 25Years Post Transplant
Patient Survival 1986 – 2015Adults vs Children
1yr 5yr 10yr 15yr 20yr 25yr
ChildNo at risk 218 173 118 67 40 16
Actuarial Survival % 89 86 83 81 76 69
Adult No at risk 963 644 410 218 99 28
Actuarial Survival % 88 77 66 57 46 39
Child (n = 265)
Adult (n = 1179)
p < .01
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 6 12 18 24Months Post Transplant
Patient Survival 2014 - 2015Adults vs Children
6m 12m 18m
ChildNo at risk 22 11 8
Actuarial Survival % 100 93 93
AdultNo at risk 92 56 27
Actuarial Survival % 97 93 92
Child (n = 30)
Adult (n = 136)
p = ns
Data to 31 December 2015 © copyright ANLTU 32
Outcome Data
Children
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Children – Weight vs OutcomePrimary Grafts
1yr 5yr 10yr 15yr 20yr 25yr
<10kg No at risk 95 72 40 20 11 5
Actuarial Survival % 84 82 80 78 78 78
>10kgNo at risk 123 101 78 47 29 11
Actuarial Survival % 93 90 86 83 76 67
<10kg (n = 119)
>10kg (n = 146)
p = ns
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Children – Type of Transplant vs OutcomePrimary Grafts
1yr 5yr 10yr 15yr 20yr 25yr
Split (n = 103)
No at risk 87 56 25
Actuarial Survival % 94 92 91
Whole(n = 70)
No at risk 61 54 46 33 17 7
Actuarial Survival % 94 94 90 88 84 79
Reduced(n = 92)
No at risk 70 63 47 34 23 9
Actuarial Survival % 79 74 72 68 63 57
Split (n = 103)
Whole (n = 70)
Reduced (n = 92)
p < .01
Data to 31 December 2015 © copyright ANLTU 33
Outcome Data
© copyright ANLTU Data to 31 December 2015
025
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100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Children – Donor TypePrimary Grafts
1yr 5yr 10yr 15yr 20yr 25yr
Split(n = 102)
No at risk 86 55 24
Actuarial Survival % 94 92 90
Whole(n = 70)
No at risk 61 54 46 33 17 7
Actuarial Survival % 94 94 90 88 84 79
Live(n = 15)
No at risk 15 11 3
Actuarial Survival % 86 86 86
Reduced(n = 78)
No at risk 59 53 46 34 23 9
Actuarial Survival % 78 73 70 66 62 55
Split (n = 102)
Whole (n = 70)
Live (n = 15)
Reduced (n = 78)
p < .01
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Fulminant Disease vs OutcomeAdults vs Children
1yr 5yr 10yr 15yr 20yr 25yr
ChildNo at risk 25 18 13 8 5 2
Actuarial Survival % 93 93 87 87 73 73
AdultNo at risk 81 61 41 25 15 4
Actuarial Survival % 75 71 64 56 46 37
Child (n = 29)
Adult (n = 114)
p < .05
Data to 31 December 2015 © copyright ANLTU 34
Outcome Data
Primary Disease and Outcome
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Primary Disease vs OutcomeAdults
Malignancy (n = 129)
PBC (n = 71)
Metabolic (n = 73)
PSC (n = 119)
Alcoholic (n = 146)
CC (n = 27)
p < . 05
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Primary Disease vs OutcomeChildren
CC (n = 3)
BA (n = 143)
FHF (n = 29)
CAH (n = 5)
Metabolic (n = 60)
Malignancy (n = 7)
p = ns
Data to 31 December 2015 © copyright ANLTU 35
Outcome Data
Status at Transplant vs Patient Outcome
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Status vs OutcomeAdults and Children – Primary Grafts
1yr 5yr 10yr 15yr 20yr 25yr
ICUNo at risk 102 69 44 26 18 6
Actuarial Survival % 77 72 67 61 55 55
At HomeNo at risk 549 362 234 116 46 16
Actuarial Survival % 93 83 75 65 59 49
Hosp. BoundNo at risk 184 119 67 46 23 7
Actuarial Survival % 84 75 65 59 47 40
Oc. InpatientNo at risk 346 267 183 101 52 15
Actuarial Survival % 86 76 65 57 46 39
ICU (n = 142)
At home (n = 642)
Hosp. Bound
(n = 239)
Oc. Inpatient
(n = 421)
p < .01
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Chronic Viral, Autoimmune Disease vs OutcomePrimary Grafts
1yr 5yr 10yr 15yr 20yr 25yr
B, CNo at risk 9 9 9 7 3 0
Actuarial Survival % 100 100 100 100 67 0
AINo at risk 45 36 27 22 15 3
Actuarial Survival % 92 82 72 62 62 57
HBVNo at risk 61 47 40 27 10 3
Actuarial Survival % 80 70 67 53 48 48
HCVNo at risk 225 126 73 28 6 2
Actuarial Survival % 89 74 60 50 31 31
B, C (n = 9)
AI (n = 54)
HBV (n = 83)
HCV (n = 270)
p = ns
Data to 31 December 2015 © copyright ANLTU 36
Outcome Data
Chronic HBV Outcomes
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Chronic HBV Before and After Prophylaxis Protocol*Primary and Secondary Indication
* Oral nucleos(t)ide therapy + low dose monthly IMI HBIG
1yr 5yr 10yr 15yr 20yr 25yr
Post23/2/1996
No at risk 89 64 44 21
Actuarial Survival % 90 81 77 64
Pre 23/2/1996
No at risk 23 20 19 17 15 3
Actuarial Survival % 72 62 56 20 47 40
Post 23/2/1996
(n = 108)
Pre 23/2/1996
(n = 32)
p = ns
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Chronic HBV (Primary and Secondary) vs Era
1yr 5yr 10yr 15yr 20yr 25yr
2006 – 2015No at risk 36 18
Actuarial Survival % 93 88
1996 – 2005No at risk 54 48 45 22
Actuarial Survival % 89 77 74 62
1986 – 1995No at risk 22 19 18 16 15 3
Actuarial Survival % 71 58 55 48 45 41
2006 – 2015 (n = 48)
1996 – 2005 (n = 61)
1986 – 1995 (n = 31)
p < .05
Data to 31 December 2015 © copyright ANLTU 37
Outcome Data
Chronic HCV Outcomes
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Chronic HCV (Primary and Secondary) vs Era
1yr 5yr 10yr 15yr 20yr 25yr
2006 – 2015No at risk 169 55
Actuarial Survival % 93 74
1996 – 2005No at risk 111 94 79 23
Actuarial Survival % 88 75 63 55
1986 – 1995No at risk 30 26 20 16 12 2
Actuarial Survival % 87 83 63 53 40 31
2006 – 2015 (n = 204)
1996 – 2005 (n = 126)
1986 – 1995 (n = 30)
p = ns
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Chronic HCV Primary vs Secondary IndicationPrimary Graft Survival
1yr 5yr 10yr 15yr 20yr 25yr
SecondaryNo at risk 69 36 17 9 3
Actuarial Survival % 92 75 57 54 54
PrimaryNo at risk 234 135 81 33 9 2
Actuarial Survival % 90 74 62 48 32 21
Secondary (n = 78)
Primary (n = 279)
p = ns
Data to 31 December 2015 © copyright ANLTU 38
Outcome Data
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
HCV vs Donor Age vs Primary Graft OutcomeAdults (n = 360)
> 60 (n = 54)
<30 (n = 86)
50 - 60 (n = 80)
30 - 50 (n = 140)
p = ns
© copyright ANLTU Data to 31 December 2015
HCV vs Donor Age vs Primary Graft OutcomeAdults (n = 360)
1yr 5yr 10yr 15yr 20yr 25yr
>60(n = 54)
No at risk 41 22 12 4 1
Actuarial Survival % 86 67 45 45 45
<30(n = 86)
No at risk 74 48 62 17 5 2
Actuarial Survival % 92 79 73 65 41 41
50 - 60(n = 80)
No at risk 68 39 9 4 4
Actuarial Survival % 89 67 50 40 28
30 - 50(n = 140)
No at risk 114 68 36 13 4
Actuarial Survival % 86 72 56 46 32
Data to 31 December 2015 © copyright ANLTU 39
Outcome Data
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Non HCV vs Donor Age vs Primary Graft OutcomeAdults (n = 819)
> 60 (n = 143)
< 30 (n = 241)
30 - 50 (n = 266)
50 - 60 (n = 169)
p = ns
© copyright ANLTU Data to 31 December 2015
Non HCV vs Donor Age vs Primary Graft OutcomeAdults (n = 819)
1yr 5yr 10yr 15yr 20yr 25yr
>60(n = 169)
No at risk 125 65 27 13 4
Actuarial Survival % 84 77 61 47 47
<30(n = 241)
No at risk 188 153 110 76 43 15
Actuarial Survival % 81 74 65 60 51 43
30 - 50(n = 266)
No at risk 214 157 106 58 22 9
Actuarial Survival % 86 76 67 56 43 36
50 - 60(n = 143)
No at risk 107 76 51 24 11
Actuarial Survival % 82 69 60 49 35
Data to 31 December 2015 © copyright ANLTU 40
Outcome Data
Donor Age vs Primary Graft Outcome
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Donor Age vs Primary Graft Outcome
> 80 (n = 8)
< 30 (n = 516)
61 - 70 (n = 140)
31 – 50 (n = 494)
51 – 60 (n = 230)
71 – 80 (n = 56)
p < .05
© copyright ANLTU Data to 31 December 2015
Donor Age vs Primary Graft Outcome
1yr 5yr 10yr 15yr 20yr 25yr
> 80(n = 8)
No at risk 5 1
Actuarial Survival % 100 100
<30(n = 516)
No at risk 408 311 219 140 74 28
Actuarial Survival % 84 77 70 65 56 49
61 – 70(n = 140)
No at risk 106 58 28 11 4
Actuarial Survival % 84 74 60 48 48
31 - 50(n = 494)
No at risk 397 275 171 84 32 11
Actuarial Survival % 85 74 64 53 41 34
51 - 60(n = 230)
No at risk 180 108 58 28 14 1
Actuarial Survival % 84 71 58 52 39 31
71 - 80(n = 56)
No at risk 41 21 8 3
Actuarial Survival % 85 77 49 43
Data to 31 December 2015 © copyright ANLTU 41
Outcome Data
Steatosis vs Graft Outcome (Adults)
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 2 4 6 8 10Years Post Transplant
Macro Steatosis vs Primary Graft Outcome (Adults)2001 - 2015
1yr 5yr 10yr
S1 Ma/MiNo at risk 45 13
Actuarial Survival % 85 76
S2 Ma/MiNo at risk 22 5
Actuarial Survival % 77 63
S0No at risk 291 113 34
Actuarial Survival % 91 79 66
S3 Ma/MiNo at risk 6 1
Actuarial Survival % 50 50
S1 Ma/Mi (n = 63)
S2 Ma/Mi (n = 22)
S0 (n = 375)
S3 Ma/Mi (n = 6)
p = .05
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 2 4 6 8 10Years Post Transplant
Micro Steatosis vs Primary Graft Outcome (Adults)2001 - 2015
1yr 5yr 10yr
S3 MiNo at risk 30 26 11
Actuarial Survival % 100 87 76
S1 MiNo at risk 79 63 27
Actuarial Survival % 92 83 66
S2 MiNo at risk 23 19 13
Actuarial Survival % 82 71 66
S0No at risk 291 113 34
Actuarial Survival % 91 79 66
S3 Mi (n = 30)
S1 Mi (n = 89)
S2 Mi (n = 28)
S0 (n = 375)
p = ns
Data to 31 December 2015 © copyright ANLTU 42
Outcome Data
Graft Survival
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Graft Survival by Graft NoAdults and Children
Tertiary (n = 15)
Primary (n = 1444)
Secondary (n = 103)
p < .01
© copyright ANLTU Data to 31 December 2015
Graft Survival by Graft NoAdults and Children
1yr 5yr 10yr 15yr 20yr 25yr
Tertiary(n = 15)
No at risk 15 9 3 2 1
Actuarial Survival % 66 66 66 66 66
Primary(n = 1444)
No at risk 1137 774 484 266 124 40
Actuarial Survival % 85 75 65 57 47 41
Secondary(n = 103)
No at risk 66 44 23 13 6 4
Actuarial Survival % 67 57 41 37 26 26
Data to 31 December 2015 © copyright ANLTU 43
Outcome Data
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 6 12 2418Months Post Transplant
Graft Survival by Graft NoAdults and Children 2014 – 2015
6m 12m 18m
TertiaryNo at risk 1
Actuarial Survival % 100
PrimaryNo at risk 113 65 29
Actuarial Survival % 96 91 91
SecondaryNo at risk 4 2 1
Actuarial Survival % 100 67 67
Tertiary (n = 1)
Primary (n = 166)
Secondary (n = 7)
p = ns
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 6 18 2412Months Post Transplant
Graft SurvivalAdults vs Children 2014 - 2015
6m 12m 18m
ChildNo at risk 23 11 8
Actuarial Survival % 100 93 93
AdultNo at risk 94 56 27
Actuarial Survival % 95 90 90
Child (n = 32)
Adult (n = 142)
p = ns
Data to 31 December 2015 © copyright ANLTU 44
Outcome Data
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Primary Graft Survival by EraAdults and Children
1yr 5yr 10yr 15yr 20yr 25yr
2006 - 2015No at risk 503 212
Actuarial Survival % 91 79
1996 - 2005No at risk 412 365 319 118
Actuarial Survival % 85 75 66 58
1986 - 1995No at risk 222 197 165 148 124 40
Actuarial Survival % 72 64 54 48 40 35
2006 – 2015 (n = 651)
1996 – 2005 (n = 486)
1986 - 1995 (n = 307)
p < .05
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Primary Graft Survival by EraAdults
1yr 5yr 10yr 15yr 20yr 25yr
2006 – 2015No at risk 417 165
Actuarial Survival % 90 77
1996 – 2005No at risk 336 294 256 97
Actuarial Survival % 85 74 64 55
1986 – 1995No at risk 179 157 127 111 90 26
Actuarial Survival % 73 64 52 45 37 30
2006 – 2015 (n = 538)
1996 – 2005 (n = 397)
1986 – 1995 (n = 244)
p < .05
Data to 31 December 2015 © copyright ANLTU 45
Outcome Data
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Primary Graft Survival by EraChildren
1yr 5yr 10yr 15yr 20yr 25yr
2006 – 2015No at risk 86 47
Actuarial Survival % 91 88
1996 – 2005No at risk 76 72 63 21
Actuarial Survival % 85 80 71 69
1986 – 1995No at risk 43 41 40 38 34 14
Actuarial Survival % 68 63 60 59 54 50
2006 – 2015 (n = 113)
1996 – 2005 (n = 89)
1986 – 1995 (n = 63)
p < . 01
Split vs Reduced vs Whole Grafts
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 2 4 6 8 10Years Post Transplant
Split vs Whole Grafts (Adults)Primary Graft Survival 2002 – 2015
1yr 5yr 10yr
SplitNo at risk 91 54 23
Actuarial Survival % 90 79 69
WholeNo at risk 487 255 102
Actuarial Survival % 90 78 67
Split (n = 110)
Whole (n = 608)
p = ns
Data to 31 December 2015 © copyright ANLTU 46
Outcome Data
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 2 4 6 8 10Years Post Transplant
Split vs Reduced vs Whole Grafts (Children)Primary Graft Survival 2002 – 2015
1yr 5yr 10yr
WholeNo at risk 19 12 7
Actuarial Survival % 96 96 96
ReducedNo at risk 25 22 6
Actuarial Survival % 90 90 80
SplitNo at risk 82 51 19
Actuarial Survival % 90 85 75
Whole (n = 25)
Reduced (n = 31)
Split (n = 102)
p = ns
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 2 4 6 8 10Years Post Transplant
Split vs Reduced vs Whole Grafts (Children)Patient Survival 2002 – 2015
1yr 5yr 10yr
WholeNo at risk 20 13 7
Actuarial Survival % 100 100 100
SplitNo at risk 87 56 25
Actuarial Survival % 95 93 91
ReducedNo at risk 31 22 8
Actuarial Survival % 90 90 90
Whole (n = 25)
Split (n = 102)
Reduced (n = 31)
p = ns
Data to 31 December 2015 © copyright ANLTU 47
Outcome Data
Cause of Death
Cause of Death
Graft Failure 122 (26.4%)
Rejection: Chronic 27 Rejection: Acute 10 Recurrent disease Hepatitis C 40 Biliary Complications 10 Hepatitis B 11 Vascular 12 PNF 4 NASH 2 Other 6
Malignancy 89 (19.3%)
De Novo 57 Recurrent disease 31 Transferred from donor 1
Sepsis 87 (18.9%)
Cardiovascular 32 (6.9%)
Cerebral 32 (6.9%)
Respiratory 25 (5.4%)
Multi-organ Failure 12 (2.6%)
Operative 11 (2.4%)
Gastrointestinal 10 (2.2%)
Vascular 8 (1.7%)
GVHD 4 (0.9%)
Renal Failure 4 (0.9%)
Other 25 (5.5%)
TOTAL 461 (34.1% of all patients)
Data to 31 December 2015 © copyright ANLTU 48
Outcome Data
© copyright ANLTU Data to 31 December 2015
Cause of Death(n = 461)
Operative2%
Sepsis19%
Cardiovascular7%
Cerebral7%
Malignancy - De Novo13%
Malignancy -Recurrent
7%
Respiratory5%
Rejection8%
GI2%
Miscellaneous11%
Recurrent Disease12%
Biliary Complications2% PNF
1%Vascular (pt)3%
Other1%
Graft failure27%
461 patients, or 34.1% of all patients transplanted, have died. Of these, 87 (18.8%) have died due to sepsis and 122 (26.5%) from graft failure. Of the 122 cases of death due to graft failure, 37 (30.3%) patients lost grafts due to rejection, 56 (45.9%) from recurrent disease and 4 (3.2%) from primary non function (PNF).
© copyright ANLTU Data to 31 December 2015
Cause of Death(n = 461)
Operative3%
Sepsis18%
Cardiovas8%
Cerebral6%
Malignancy20%
Respiratory5%
GI2%
Misc11%
Graft Failure27%
Adults (n = 413)
Sepsis23%
Cardiovas2%
Cerebral17%
Malignancy10%
Respiratory8%
GI2%
Misc15%
Graft Failure23%
Children (n = 48)
The majority of adult deaths were due to Graft Failure (111 or 26.9%), Malignancy (84 or 20.3%) and Sepsis (76 or 18.4%). The majority of child deaths were due to Graft Failure (11 or 22.9%), Sepsis (11 or 22.9%) and Cerebrovascular accident (8 or 16.7%).
Data to 31 December 2015 © copyright ANLTU 49
Outcome Data
© copyright ANLTU Data to 31 December 2015
7 7 7 6 3 1
152
2
41
2
14
1
1
42
26
20
12
83
22
14
98
13
242
1
16
10
7
6 5
28
3
9
3
3
4 1
1
40
1114
44
3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<1 year 1 - 5 years 5 - 10 years 10 - 15 years
15 - 20 years
>20 years
Sepsis
Respiratory
Operative
Miscellaneous
Recurrent Malignancy
De Novo Malignancy
Graft Failure
Gastrointestinal
Cerebral
Cardiovascular
Cause of Death by Time - Adults(n = 413; 39.6% of adults)
© copyright ANLTU Data to 31 December 2015
18
7 2
11
1
1
21
5
2
2
1
1
6 1
2
1
1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<1 year 1 - 5 years 5 - 10 years 10 - 15 years
15 - 20 years
>20 years
Gastrointestinal
Sepsis
Respiratory
Miscellaneous
Recurrent Malignancy
De Novo Malignancy
Graft Failure
Cerebral
Cardiovascular
Cause of Death by Time - Children(n = 48; 20.4% of children)
Data to 31 December 2015 © copyright ANLTU 50
Outcome Data
© copyright ANLTU Data to 31 December 2015
10 14 7
15 4 5
4748
16
1624
14
8 9
13
14 16 169 6
628 35
136 3 24 4 1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1986 - 1995 1996 - 2005 2006 - 2015
GI
Operative
Sepsis
Respiratory
Miscellaneous
Recurrent Malignancy
De Novo Malignancy
Graft Failure
Cerebral
Cardiovascular
Cause of Death by Transplant Era - Adults(n = 413; 39.6% of adults)
© copyright ANLTU Data to 31 December 2015
1
5
21
4 6 1
41
4
2
113
7 31
1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1986 - 1995 1996 - 2005 2006 - 2015
GI
Sepsis
Respiratory
Miscellaneous
Recurrent Malignancy
De Novo Malignancy
Graft Failure
Cerebral
Cardiovascular
Cause of Death by Transplant Era - Children(n = 48; 20.4% of children)
Data to 31 December 2015 © copyright ANLTU 51
Outcome Data
© copyright ANLTU Data to 31 December 2015
Cause of Death – HCV Recipients(n = 121)
Cardiovascular5%
Gastrointestinal1%
Other Graft Failure4%
Malignancy - De Novo12%
Malignancy -Persistent
13%
Operative4%
Sepsis15%
Respiratory1%
Recurrent HCV32%
Other 13%
Data to 31 December 2015 © copyright ANLTU 52
Outcome Data
Cause of Graft Failure
Cause of Graft Failure Rejection 71 (12.3%) Acute 15 Chronic 49 ABO incompatibility 6 Subacute 1 Vascular complications 46 (7.9%) Hepatic artery thrombosis 36 Portal vein thrombosis 4 Dissection in donor 1 Graft infarction 1 Graft compression 1 Hepatic vein stenosis 1 Rupture 1 Vena Cava obstruction 1 Recurrent disease 97 (16.8%) Hep C 47 Malignancy 27 Hep B 13 PSC 5 NASH 3 Alcohol 1 Cryptogenic cirrhosis 1 Primary non function 21 (3.6%) Graft infarction 7 Severe steatosis 2 Antibody mediated rejection 1 Arterial thrombosis 1 Blood loss 1 HA occlusion 1 Preservation injury 1 Profound hypotension 1 Vena 1 Other 5 Patient deaths 295 (50.9%) Sepsis 80 Malignancy 61 Cerebral 32 Cardiovascular 26 Respiratory failure 25 Intraoperative 15 GI haemorrhage 8 GVHD 4 Pancreatitis 3 Other 41 Biliary complications 31 (5.3%) Biliary strictures 21 Other 10 Other 18 (3.1%) TOTAL 579 (42.8%) of all grafts
Data to 31 December 2015 © copyright ANLTU 53
Outcome Data
© copyright ANLTU Data to 31 December 2015
Cause of Graft Failure(n = 579)
Rejection12%
PNF4%
Vascular8%
Recurrent Disease17%
Other3% GVHD
1%
Malignancy11%
Other6%
Cardiac4% Intraop
3%Respiratory4%
Cerebral6%
Sepsis14%
GI1%
Biliary5%
Pancreatitis1%
Patient Death51%
579 of 1562 grafts (37.1%) have failed. 295 grafts (50.9%) were lost due to patient deaths, 97 (16.8%) due to disease recurrence and 71 (12.3%) due to rejection. Sepsis was the most significant cause of patient death (83 patients), followed by malignancy (62 patients) and cerebral catastrophe (32 patients).
© copyright ANLTU Data to 31 December 2015
Cause of Graft Failure(n = 579)
Rejection10%
PNF3%
Patient Death54%
Vascular6%
Recurrent Disease
20%
Other 3%
Biliary4%
Adults (n = 486)
Rejection24%
PNF7%
Patient Death33%
Vascular18%
Other 6%
Biliary12%
Children (n = 93)
Patient death was the most significant cause of graft failure, followed by rejection.
Data to 31 December 2015 © copyright ANLTU 54
Outcome Data
© copyright ANLTU Data to 31 December 2015
4 3 5 4 22
3 43 1
1
15
104
52
49
3120
8
26 40
20
7
427
97
1
4122
5 1 1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<1 year 1 - 5 years 5 - 10 years 10 - 15 years
15 - 20 years
>20 years
Vascular
Rejection
Recurrent Disease
Pt Death
PNF
Other
Biliary
Cause of Graft Failure by Time - Adults(n = 486; 38.7% of adult grafts)
© copyright ANLTU Data to 31 December 2015
2 1
53
21
1
2
6
24
2
2
1
1
1
7
7
5 1
1
1
12 4
1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<1 year 1 - 5 years 5 - 10 years 10 - 15 years
15 - 20 years
>20 years
VascularRejectionPt DeathPNFOtherBiliary
Cause of Graft Failure by Time - Children(n = 93; 30.4% of child grafts)
Data to 31 December 2015 © copyright ANLTU 55
Outcome Data
© copyright ANLTU Data to 31 December 2015
9 10 12 3 71 6 8
94106
64
32
4124
33 115
7 16 6
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1986 - 1995 1996 - 2005 2006 - 2015
Vascular
Rejection
Recurrent Disease
Pt Death
PNF
Other
Biliary
Cause of Graft Failure by Transplant Era - Adults(n = 486; 38.7% of adult grafts)
© copyright ANLTU Data to 31 December 2015
36
21
2 3
4
218
8
5
10
9
3
6
9
2
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1986 - 1995 1996 - 2005 2006 - 2015
VascularRejectionPt DeathPNFOtherBiliary
Cause of Graft Failure by Transplant Era - Children(n = 93; 30.4% of child grafts)
Data to 31 December 2015 © copyright ANLTU 56
Outcome Data
Data to 31 December 2015 © copyright ANLTU 57
CANCER AND
TRANSPLANTATION
Data to 31 December 2015 © copyright ANLTU 58
Cancer and Transplantation
Malignancy at Transplantation
© copyright ANLTU Data to 31 December 2015
1 2 1 1 2 13
7
119
11
7 79
15 14
11
18
12
18
15
25
19 20
23 22
1
1
11 2 1
1
1
11
1 2
1
1 2
2
1
3
1
1
1
1
1
1
2
2
1
1
0
5
10
15
20
25
3019
8719
8819
8919
9019
9119
9219
9319
9419
9519
9619
9719
9819
9920
0020
0120
0220
0320
0420
0520
0620
0720
0820
0920
1020
1120
1220
1320
1420
15
Cholangiocarcinoma (n = 16)Miscellaneous (n = 18)Hepatoblastoma (n = 2)HCC (n = 284)
Malignancy at Transplantation(n = 296 Pts/320 Ca; 20.4% of patients)
© copyright ANLTU Data to 31 December 2015
1 1 1 13
21 1
5
87 7
5 5
8
14
1110
14
9
16
13
20
13
1720
17
1 1
2
2
3
24
2 2
1
1
3
3
2
2
2
5
6
2
3
5
0
5
10
15
20
25Unknown Pre Tx: Found in Explant (n = 54)
Known Pre Tx: Confirmed at Explant (n = 226)
Chemo or Injection Pre Tx: No Tumour at Explant (n = 4)
HCC at Transplantation(n = 284)
Data to 31 December 2015 © copyright ANLTU 59
Cancer and Transplantation
© copyright ANLTU Data to 31 December 2015
Cancer in Liver Transplant Recipients1986 - 2015
At Transplant (1444 patients) Patients (n,%)
Liver cancer as primary diagnosis 136 9.4%
Liver cancer as secondary diagnosis 174 12.0%
No. of Patients with a cancer diagnosis at transplant 310 21.5%
Post Transplant
Recurrent liver cancer 36 2.5% of all pts, 11.6% of cancer at tx pts
De novo non-skin cancer 114 7.9% of all pts, 36.8% of cancer at tx pts
De novo skin cancer 207 14.3% of all pts, 66.8% of cancer at tx pts
No. of Patients with a post transplant cancer 357 24.7% of all pts
Patients with multiple cancers 197 13.6% of all pts
Pre transplant cancer developed de novo cancer 61 19.6% of cancer at tx pts
Transferred from donor 4
Developed non-skin cancer within 90 days 1
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20Years Post Transplant
HCC vs EraPrimary and Secondary Indication
1yr 5yr 10yr 15yr 20yr
2006 – 2015No at risk 149 50
Actuarial Survival % 94 74
1996 – 2005No at risk 79 66 57 18
Actuarial Survival % 85 71 61 51
1986 – 1995No at risk 8 5 5 3 2
Actuarial Survival % 63 50 50 38 25
2006 – 2015 (n = 183)
1996 – 2005 (n = 93)
1986 – 1995 (n = 8)
p = ns
Data to 31 December 2015 © copyright ANLTU 60
Cancer and Transplantation
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Benign Disease vs Malignancy
1yr 5yr 10yr 15yr 20yr 25yr
BenignNo at risk 928 686 463 261 134 43
Actuarial Survival % 87 81 72 63 54 45
MalignancyNo at risk 253 131 65 24 5 1
Actuarial Survival % 89 71 61 49 34 34
Benign (n = 1134)
Malignant (n = 310)
p < . 01
© copyright ANLTU Data to 31 December 2015
025
5075
100
% S
urvi
ving
0 5 10 15 20 25Years Post Transplant
Primary and Secondary HCC vs No HCC
No HCC (n = 1267)
With HCC (n = 295)
p = ns
1yr 5yr 10yr 15yr 20yr 25yr
No HCCNo at risk 1018 752 497 282 146 45
Actuarial Survival % 86 78 69 61 52 46
With HCCNo at risk 242 125 61 20 2
Actuarial Survival % 90 73 64 52 38
Data to 31 December 2015 © copyright ANLTU 61
Cancer and Transplantation
De Novo Non Skin Cancer Post Transplant
© copyright ANLTU Data to 31 December 2015
De Novo Cancer (Excluding Skin)n = 114 Pts, 123 Ca; 8.4% pts transplanted
No Male FemaleAge of
patients (years)
Time to diagnosis (months)
Died of This Cancer
Died Other
Alimentary 48 37 1113 - 78
(m = 59)0 - 266
(m = 74)23 48% 8
Lymphoma (inc PTLD) 27 16 111 - 70
(m = 49)4 -281
(m = 87 )8 30% 6
Genitourinary 15 12 321 - 74
(m = 59)2 - 228
(m = 83)2 13% 5
Respiratory 11 9 229 - 68
(m = 61)7 - 193
(m = 56)8 73% 0
Breast 9 0 930 - 60
(m = 44)50 - 252
(m = 135)6 67% 1
Endocrine 8 2 636 - 70
(m = 48)14 - 144(m = 56)
2 25% 0
CNS 2 1 166 - 75
(m = 70)14 - 93
(m = 53)2 100% 0
Bone 1 0 1 69 69 1 100% 0
Fibrous Histiocytoma 1 0 1 62 120 0 0
Kaposi’s 1 1 0 32 48 0 1
Total 123 78 451 - 78
(m = 56)0 - 281
(m = 69)52 42% 21
NB: m = median
© copyright ANLTU Data to 31 December 2015
De Novo Cancer (Excluding Skin)n = 114 Pts, 123 Ca; 8.4% pts transplanted
Breast7%
CNS2%
Endocrine6%
Genitourinary12%
Kaposi's Sarcoma
1%
Lymphoma22%
Respiratory9%
Lower GI27%
Pancreas5%
Upper GI7%
Fibrous Histiocytoma1%
Bone1%
Alimentary40%
Data to 31 December 2015 © copyright ANLTU 62
Cancer and Transplantation
Pre Transplant Liver Disease and De Novo Non Skin Cancer
© copyright ANLTU Data to 31 December 2015
Pre Transplant Liver Disease andDe Novo Cancer (Excluding Skin)
n = 123
7
5 5
4
3
1 1 1
0
1
2
3
4
5
6
7
PSC + Autoimmune27/; 22% of all De Novo
3
2 2 2 2
1 1
0
1
2
3
4
5
6
7
HBV14/; 11% of all De Novo
© copyright ANLTU Data to 31 December 2015
Pre Transplant Liver Disease andDe Novo Cancer (Excluding Skin)
n = 123
6
5
4 4
2 2
1 1
0
1
2
3
4
5
6
7
8
HCV25/123; 20% of all De Novo
8
5
4
2 2
1 1 1 1
0
1
2
3
4
5
6
7
8
Alcohol25/123; 20% of all De Novo
Data to 31 December 2015 © copyright ANLTU 63
Cancer and Transplantation
© copyright ANLTU Data to 31 December 2015
12 1210
5
1
5 5
1
3
4
3
4
2
3
2
1
2
3
0
5
10
15
20
25
PSC + AI HCV ALD HBV PBC
Bone (n = 1)Fibrous Histiocytoma (n = 1)Respiratory (n = 5)Kaposi's Sarcoma (n = 1)Genitourinary (n = 11)Endocrine (n = 7)Lymphoma (n = 14)Alimentary (n = 40)
Primary Liver Disease andDe Novo Cancer (Excluding Skin)
© copyright ANLTU Data to 31 December 2015
1
5
16
13 13
1
3
5
1 1
4
3
11
2 2
3
7
1
3
5
8
11
1
5
1
4
1
0
2
4
6
8
10
12
14
16
0 - 6 months 6 - 12 months 1 - 5 years 5 - 10 years >10 years
Alimentary (n = 48)Breast (n = 9)CNS (n = 2)Endocrine (n = 8)Genitourinary (n = 15)Kaposi's Sarcoma (n = 1)Lymphoma (n = 27)Respiratory (n = 11)Fibrous Histiocytoma (n = 1)Bone (n = 1)
Time to DiagnosisDe Novo Cancer (Excluding Skin)
Data to 31 December 2015 © copyright ANLTU 64
Cancer and Transplantation
Cumulative Risk of Diagnosis of Cancer
© copyright ANLTU Data to 31 December 2015
Cumulative Risk of Diagnosis of CancerFollowing Liver Transplantation 1986 – 2015
0
20
40
60
80
100
0 5 10 15 20 25Years Post Tx
Any CancerSkinDe Novo Non SkinAge Matched Gen. Pop