A0475 - Risk Stratification of Pre-Liver Transplant Polypectomy

Sunday, October 23, 2022

5:00 PM – 7:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Paul Travers, MD

Mayo Clinic
Jacksonville, FL

Paul Travers, MD¹, Pedro Cortés, MD¹, Maoyin Pang, MD, PhD², Ashton Body, ³, William C. Palmer, MD¹
¹Mayo Clinic, Jacksonville, FL; ²Mayo Clinic Florida, Jacksonville, FL; ³Harvard University, Jacksonville, FL

Introduction: Screening colonoscopies are frequently obtained during the pretransplant workup of a patient prior to liver transplant, however the utility is controversial. While colonoscopies are generally safe and well tolerated procedures, the patients in this population are at an elevated risk for procedural complications. Recent studies have shown the neoplastic yield of pre-transplant colonoscopies to be poor, and only significant in patients above 50 years old. Even so, the detection and treatment of pre-malignant abnormalities is of clinical relevance, as the required immunosuppression after transplantation increases the risk of progression to frank malignancy. There is currently no well-studied way to risk stratify these patients prior to colonoscopy and polypectomy.

Methods: This was a retrospective study of patients aged 18 and older who underwent liver transplant between April 1, 2012, and April 1, 2022. Included patients had undergone colonoscopy within 90 days of liver transplantation. Collected data included cause of ESLD, pre-colonoscopy lab work, colonoscopic findings, polypectomy method, polyp morphology and histopathology, and post-colonoscopy complications. Comparisons between groups were made using a Wilcoxon rank sum test or Fisher’s exact test.

Results: Of 1000 patients with liver transplantation, 75 met inclusion criteria. Due to small sample size, a p-value of 0.10 was used to define statistical significance. 39.2% of patients underwent polypectomy during pre-transplant colonoscopy. Patients who underwent polypectomy experienced all-cause post-procedural complications at an increased rate (p=0.097). Every 1-point increase in pre-colonoscopy MELD-Na score was associated with increased rates of all-cause post-procedural complications (0.001). Complications of cirrhosis were also associated with post-procedural complications (ascites, p=0.070; SBP, p=0.073).

Discussion: Among patients undergoing pre-liver transplant colonoscopy, there was a statistically significant increase in risk for post-procedural complications based on increased MELD-Na score prior to colonoscopy. In addition, completing polypectomy during pre-liver transplant colonoscopy seems so be associated with an increased risk of post-procedural complications, although the number and size of polyps removed did not change risk. This study seems to show that pre-liver transplant colonoscopy is associated with complications around the time of liver transplantation, worsened still by polypectomy during said colonoscopy.

Figure: Figure 1. Multivariable Logistic Regression for Any Complication
On multivariable analysis for any complication following pre-liver transplant colonoscopy, adjusting for age, MELD-Na, and prior SBP, a polypectomy approached significance (HR 2.41, 95% CI: 0.84-7.36, p=0.11)

Baseline Characteristics Median (IQR) or Fraction (%)		Univariable Analysis Median (IQR) or Fraction (%)			Logistic Regression Any Complication		Logistic Regression Acute Renal Failure
	All Patients N=75	No Complication N=35	Complication N=40	P value	OR (95% CI)	P value	OR (95% CI)	P value
Age at liver transplant, per 1 year	58.5 (54.9-65.0)	58.5 (53.0-63.4)	58.5 (55.3-65.5)	0.51¹	1.04 (0.99-1.09)	0.13	1.08 (0.997-1.17)	0.0594
< · Age ≥ 65 years	19/75 (25.3%)	7/35 (20.0%)	12/40 (30.0%)	0.43²	1.71 (0.59-4.99)	0.32	3.50 (1.05-11.65)	0.0411
Male gender	50/75 (66.7%)	23/35 (65.7%)	27/40 (67.5%)	1.00²	1.08 (0.41-2.83)	0.87	0.41 (0.13-1.28)	0.22
White Race	69/75 (92.0%)	33/35 (94.3%)	36/40 (90.0%)	0.68²	0.55 (0.09-3.18)	0.50	1.18 (0.12-11.34)	0.89
Never Smoker	31/73 (42.5%)	16/34 (47.1%)	15/39 (38.5%)	0.49²	0.70 (0.28-1.79)	0.46	0.94 (0.30-2.90)	0.91
Etiology of Cirrhosis
HCV	17/75 (22.7%)	7/35 (20.0%)	10/40 (25.0%)	0.78²	1.33 (0.45-3.98)	0.61	1.08 (0.29-3.91)	0.91
NASH	25/75 (33.3%)	14/35 (40.0%)	11/40 (27.5%)	0.33²	1.38 (0.79-2.42)	0.26	0.86 (0.26-2.84)	0.81
Alcohol	18/75 (18.0%)	6/35 (17.1%)	12/40 (30.0%)	0.28²	2.07 (0.68-6.28)	0.20	2.15 (0.65-7.12)	0.21
Other	22/75 (29.3%)	11/35 (31.4%)	11/40 (27.5%)	0.80²	0.83 (0.31-2.23)	0.71	0.56 (0.14-2.24)	0.42
Complications from Cirrhosis
Ascites	55/75 (73.3%)	22/35 (62.9%)	33/40 (82.5%)	0.070²	2.79 (0.96-8.09)	0.0595	1.23 (0.35-4.39)	0.75
Hepatocellular Carcinoma	12/75 (16.0%)	5/35 (14.3%)	7/40 (17.5%)	0.76²	1.27 (0.36-4.44)	0.71	1.18 (0.28-5.00)	0.82
Hepatic Encephalopathy	61/75 (81.3%)	26/35 (74.3%)	35/40 (87.5%)	0.23²	2.42 (0.72-8.08)	0.15	1.95 (0.39-9.81)	0.42
< · Grade 1 or 2	50/54 (92.6%	21/23 (91.3%)	29/31 (93.5%)	1.00²	1.38 (0.18-10.61)	0.75	1.06 (0.10-11.18)	0.96
< · Grade 3 or 4	4/54 (7.4%)	2/23 (8.7%)	2/31 (6.5%)	1.00²	0.72 (0.09-5.56)	0.75	0.94 (0.09-9.97)	0.96
Esophageal varices	38/75 (50.7%)	18/35 (51.4%)	20/40 (50.0%)	1.00²	0.94 (0.38-2.34)	0.90	1.04 (0.34-3.16)	0.95
Spontaneous bacterial peritonitis	13/75 (17.3%)	3/35 (8.6%)	10/40 (25.0%)	0.073²	3.56 (0.89-14.18)	0.0722	1.96 (0.50-7.61)	0.33
Hepatorenal syndrome	10/75 (13.3%)	6/35 (17.1%)	4/40 (10.0%)	0.50²	0.54 (0.14-2.08)	0.37	2.72 (0.66-11.20)	0.17
Hepatopulmonary syndrome	3/75 (4.0%)	2/35 (5.7%)	1/40 (2.5%)	0.60²	0.42 (0.04-4.9)	0.49	NA	NA
Hemodialysis-dependent	68/71 (4.2%)	2/35 (5.7%)	1/36 (2.8%)	0.61²	0.47 (0.04-5.45)	0.55	1.79 (0.15-21.17)	0.65
Labs prior at time of colonoscopy
Sodium, per 1 mg/dL	135 (131-138)	135 (132.5-139.0)	134 (130.8-138.0)	0.23¹	0.96 (0.89-1.05)	0.38	0.96 (0.87-1.07)	0.47
Total bilirubin, per 1 mg/dL	4.5 (1.9-8.7)	3.0 (1.4-6.4)	5.7 (2.7-16.2)	0.011¹	1.09 (1.01-1.18)	0.0203	1.08 (1.02-1.14)	0.0059
INR, per 1 point	1.9 (1.4-2.4)	1.7 (1.3-2.1)	2.0 (1.6-2.5)	0.019¹	2.65 (1.10-6.42)	0.0304	3.29 (1.14-9.55)	0.0282
Albumin, per 1 mg/dL	3.2 (2.8-3.7)	3.6 (2.9-3.9)	3.0 (2.7-3.4)	0.007¹	0.34 (0.15-0.76)	0.0091	0.78 (0.32-1.92)	0.59
Creatinine, per 1 mg/dL	1.1 (0.9-1.8)	1.0 (0.8-1.5)	1.2 (0.9-2.0)	0.10¹	1.19 (0.86-1.65)	0.29	1.16 (0.84-1.58)	0.37
MELD score, per 1 point	21 (15.5-26.5)	19.0 (12.0-22.5)	23.5 (18.0-29.3)	0.002¹	1.11 (1.04-1.19)	0.0024	1.15 (1.05-1.25)	0.0017
MELD-Na score, per 1 point	25 (18.3-29.6)	21.0 (12.2-26.9)	27.3 (21.8-31.1)	0.001¹	1.11 (1.04-1.18)	0.0020	1.18 (1.06-1.31)	0.0023
< · MELD-Na ≥ 30	17/75 (22.7%)	3/35 (8.6%)	14/40 (35.0%)	0.011¹	5.74 (1.49-22.15)	0.0111	5.87 (1.71-20.18)	0.0049
Colonoscopy Data
Bowel Prep Adequate	59/74 (79.7%)	26/34 (76.5%)	33/40 (82.5%)	0.57²	1.45 (0.47-4.52)	0.52	2.00 (0.40-10.06)	0.40
Total Number of Polyps Found, per 1 polyp	0 (0-1)	0 (0-1)	0 (0-1)	0.14¹	1.23 (0.85-1.79)	0.27	0.71 (0.37-1.35)	0.30
Polypectomy Performed	29/74 (39.2%)	10/35 (28.6%)	19/39 (48.7%)	0.097²	2.37 (0.90-6.23)	0.0791	0.87 (0.26-2.92)	0.82
Polyp > 10 mm Removed	8/29 (27.6%)	4/10 (40.0%)	4/19 (21.1%)	0.39²	0.40 (0.7-2.14)	0.29	0.46 (0.04-4.99)	0.53
Rectal varices present	8/75 (10.7%)	5/35 (14.3%)	3/40 (7.5%)	0.46²	0.49 (0.11-2.20)	0.35	0.46 (0.05-4.02)	0.48
Hemorrhoids present	10/75 (13.3%)	3/35 (8.6%)	7/40 (17.5%)	0.32²	2.26 (0.54-9.52)	0.27	0.98 (0.18-5.26)	0.98
Diverticula present	14/75 (18.7%)	10/35 (28.6%)	4/40 (10.0%)	0.072²	0.28 (0.08-0.99)	0.0475	NA	NA
Outcomes (Complications at 30 days post-colonoscopy)
Any complications (primary composite outcome)	40/75 (53.3%)	NA	NA	NA	NA	NA	NA	NA
< · Acute renal failure	16/71 (21.3%)	NA	NA	NA	NA	NA	NA	NA
< · GI Bleed	5/72 (6.7%)	NA	NA	NA	NA	NA	NA	NA
< · New ascites	6/71 (8.0%)	NA	NA	NA	NA	NA	NA	NA
< · New hepatic encephalopathy	11/74 (14.7%)	NA	NA	NA	NA	NA	NA	NA
< · Cardiopulmonary, any	10/75 (13.3%)	NA	NA	NA	NA	NA	NA	NA
< · Infection, any	11/75 (14.7%)	NA	NA	NA	NA	NA	NA	NA

Table: Table 1. Baseline Characteristics Followed by Univariable Analysis and Unadjusted Logistic Regression Analysis for Any Complication or Acute Renal Failure Within 30 Days After Pre-Transplant Colonoscopy
NA = Not Applicable
1. Wilcoxon Rank Sum Test
2. Fisher's Exact Test

Disclosures:

Paul Travers indicated no relevant financial relationships.

Pedro Cortés indicated no relevant financial relationships.

Maoyin Pang indicated no relevant financial relationships.

Ashton Body indicated no relevant financial relationships.

William Palmer indicated no relevant financial relationships.

Paul Travers, MD¹, Pedro Cortés, MD¹, Maoyin Pang, MD, PhD², Ashton Body, ³, William C. Palmer, MD¹. A0475 - Risk Stratification of Pre-Liver Transplant Polypectomy, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.