Nationwide Analysis of Failure to Rescue After Liver Transplantation

Introduction: Failure to rescue (FTR) is mortality after a major complication. FTR may be an effective quality metric in liver transplantation (LT). However, there is a paucity of nationwide data on the rates and effects of FTR on outcomes. Our study aims to determine the nationwide rate of FTR and its impact on outcomes after LT. Methods: We analyzed the 2015–2017 Nationwide Readmissions Database, including all patients with LT. Patients were stratified into terciles of average center mortality of < 1% for low (L), 1%–5.76% for intermediate (I), and > 5.76% for high (H). Postoperative complications were identified. Primary outcomes were the rate of FTR and the predictors of FTR. Multivariable regression analysis was performed. Results: A total of 12,134 patients with LT were identified at 82 centers. The sample was stratified into L: 1770 (14.6%), I: 5914 (48.7%), and H: 4450 (36.7%). The mean age was 52.2 ± 16.6 years, and 63.1% were male. Of these, 99.7% underwent deceased-donor LT, most commonly due to alcoholic cirrhosis (31.9%), followed by metabolic steatohepatitis (20.7%). The rate of FTR was 5%, with the most common complication being renal failure at 60.6%, followed by respiratory failure at 43.1%. FTR rate differences were significant (H: 8.8% vs. I: 3.6% vs. L: 1.3%; p < 0.01). Multivariable logistic regression demonstrated an independent association between FTR and H (odds ratio [OR] 1.79 [1.52–1.89]). The predictors of FTR were both patient- and center-related: low-income quartile (OR 1.23 [1.11–1.39]), malnutrition (OR 1.22 [1.09–1.29]), presenting diagnosis of biliary atresia (OR 3.39 [1.95–5.93]), presenting diagnosis of acute liver failure (OR 5.01 [4.09–6.15]), Charlson Comorbidity Index [CCI] (OR 1.24 [1.18–1.31]), frailty (OR 1.58 [1.46–1.73]), LT at a low-volume center (< 20 cases/year) (OR 1.83 [1.78–2.01]), and readmission to a different hospital (OR 2.08 [1.78–2.11]). Protective factors were LT at a metropolitan teaching hospital (OR 0.96 [0.87–0.99]), presenting a diagnosis of primary hepatic malignancy (OR 0.66 [0.52–0.86]), high-income quartile (OR 0.74 [0.57–0.96]), disposition to rehab (OR 0.09 [0.03–0.26]), and high-volume centers (> 50 cases/year) (OR 0.32 [0.20–0.49]). Conclusions: FTR remains a critical issue in LT, with significant variability across centers. These findings demonstrate associations, not causation, between center- and patient-level factors and FTR rates. Identifying and addressing modifiable predictors of FTR presents opportunities for improving perioperative management and postoperative care.