Preoperative Prognostic Nutritional Index as Independent Predictor of Overall Survival on Hepatocellular Carcinoma after Liver Transplantation
Oana Anisa Nutu1, Iago Justo Alonso1, María García Conde Delgado1, Alberto Marcacuzco Quinto1, Alejandro Manrique Municio1, Pilar Del Pozo Elso1, Isabel Lechuga Alonso1, Óscar Caso Maestro1, Marina Pérez-Flecha1, Jorge Calvo Pulido1, Carlos Jiménez Romero1.
1Hepatobiliopancreatic Surgery and Abdominal Organs Transplantation Unit, Hospital 12 Octubre, Madrid, Spain
Background: Malnutrition and inmunological status are associated with worse survival in many cancers. Preoperative nutritional index (PNI) is calculated according to the serum albumin concentration and total lymphocyte count (ALC) in the peripheral blood. This index was originally proposed to assess the perioperative inmunonutritional status and surgical risk in patients undergoing gastrointestinal surgery and later in patients with hepatocellular carcinoma (HCC) undergoing liver resection.
The aim of this study is to evaluate the prognostic value in terms of overall survival of PNI in patients with HCC after liver transplantation (LT).
Material and methods: We performed a retrospective study during the period between 2006-2016. Excluding HIV positive recipients, split grafts, simultaneos liver-kidney transplantation, donors older than 70 years, we analyzed 404 patients. There were 144 recipients transplantated for HCC. The preoperative PNI was calculated using albumin and ALC on admission for liver transplant,following this formula: serum albumin (g/dL)x10+0,005xALC (mm3).
Results: A total of 144 patients with HCC were included in the study. There were 120 men (83%), with a median age of 58+-7 years. Hundred patients (69,4%) were HCV+, 41 received a DCD (donation after cardiac death) donor type II graft and 103 received a BDD donor. HCC recurred in 10 patients (7%). Of these patients, 116 fulfilled the Milan criteria, 35 the UCSF criteria and 3 were beyond UCSF.
Regarding the PNI, the median value was 40,9+-8,3. The AUC was 0,753 (p=0,08), and the Younden index was highest when PNI was 45: the S was 75% and E, 75% also. One ,3 and 5 years overall survival were 99%, 84% and 79% in patients with PNI>45 higher than 85%, 70% and 64% in PNI<45. Comparing in both groups the clinical characteristics like age, gender, HCV proportion or listing AFP , we did not find significant differences. Patients with PNI<45 showed significantly higher number of nodules before LT (p<0,05) and microvascular invasion than those with PNI >45 (p<0,05). During the surgery patients with PNI<45 requiered more platelets, plasma or red blood cell transfussion than those with PNI>45 (p<0,001), being 1,4 the median McCluskey index in PNI>45 group and 2,6 in PNI<45 (p<0,05) .
Discussion: PNI is the result of low hipoalbuminemia and lymphocytopenia. As we all know, albuminemia has been already used in several staging systems to asess the liver function. But behind its correlation with malnutrition, it is thought to be also an indirect meassure of the level of inflamation and tumour progression. In our study, PNI grade was also a good indicator of transfusional requirements.
Conclusion: Though we need a larger sample size and a longer follow up, PNI before LT for HCC seems to be useful as prognostic factor for overall survival and for transfusional requirements.
