BACKGROUND AND AIMS: Management of Budd-Chiari syndrome (BCS) has improved over the last decades. The main aim was to evaluate the contemporary post-liver transplant (post-LT) outcomes in Europe. APPROACH AND RESULTS: Data from all patients who underwent transplantation from 1976 to 2020 was obtained from the European Liver Transplant Registry (ELTR). Patients < 16 years, with secondary BCS or HCC were excluded. Patient survival (PS) and graft survival (GS) before and after 2000 were compared. Multivariate Cox regression analysis identified predictors of PS and GS after 2000. Supplemental data was requested from all ELTR-affiliated centers and received from 44. In all, 808 patients underwent transplantation between 2000 and 2020. One-, 5- and 10-year PS was 84%, 77%, and 68%, and GS was 79%, 70%, and 62%, respectively. Both significantly improved compared to outcomes before 2000 ( p < 0.001). Median follow-up was 50 months and retransplantation rate was 12%. Recipient age (aHR:1.04,95%CI:1.02-1.06) and MELD score (aHR:1.04,95%CI:1.01-1.06), especially above 30, were associated with worse PS, while male sex had better outcomes (aHR:0.63,95%CI:0.41-0.96). Donor age was associated with worse PS (aHR:1.01,95%CI:1.00-1.03) and GS (aHR:1.02,95%CI:1.01-1.03). In 353 patients (44%) with supplemental data, 33% had myeloproliferative neoplasm, 20% underwent TIPS pre-LT, and 85% used anticoagulation post-LT. Post-LT anticoagulation was associated with improved PS (aHR:0.29,95%CI:0.16-0.54) and GS (aHR:0.48,95%CI:0.29-0.81). Hepatic artery thrombosis and portal vein thrombosis (PVT) occurred in 9% and 7%, while recurrent BCS was rare (3%). CONCLUSIONS: LT for BCS results in excellent patient- and graft-survival. Older recipient or donor age and higher MELD are associated with poorer outcomes, while long-term anticoagulation improves both patient and graft outcomes.

Center for Organ Transplantation Medipol University Hospital Istanbul Turkey

Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation IRCCS ISMETT Palermo Italy

Department of Abdominal Surgery and Transplantation CHU Liege Liege Belgium

Department of abdominal surgery Unit of Hepato biliary surgery and Liver Transplantation Hôpital Erasme Cliniques Universitaires de Bruxelles Brussels Belgium

Department of Abdominal Transplant Surgery Universitaire Ziekenhuizen Leuven Belgium

Department of Biostatistics Erasmus University Medical Center Rotterdam The Netherlands

Department of Digestive Surgery and Liver Transplantation Pitie Salpetriere university hospital Sorbonne University Paris France

Department of Gastroenterology and Hepatology C H U de Grenoble Grenoble France

Department of Gastroenterology and Hepatology Erasmus MC Transplant Institute Erasmus MC University Medical Center Rotterdam the Netherlands

Department of Gastroenterology and Hepatology University Medical Center Groningen Groningen the Netherlands

Department of Gastroenterology and Transplantation Università Politecnica delle Marche Ancona Italy

Department of Gastroenterology University Medical Center Lubljana Ljubljana Slovenia

Department of General and Digestive Surgery Clinica Universitaria de Navarra Pamplona Spain

Department of General and Digestive Surgery Hospital Universitario Rio Hortega Valladolid Spain

Department of General and HPB Surgery and Liver Transplantation University Hospital Gent Ghent Belgium

Department of General Surgery and Transplantation ASST Grande Ospedale Metropolitano Niguarda University of Milano Bicocca Milan Italy

Department of General Surgery International Liver Center and Acibadem Health Care Hospitals Istanbul Turkey

Department of General Visceral and Transplant Surgery Universitätsklinik Tübingen Tubingen Germany

Department of General Visceral Vascular and Transplant Surgery University Hospital Magdeburg Germany

Department of HBP Surgery and Liver Transplantation Cruces University hospital Bilbao Spain

Department of Hepato Biliary Surgery Cancer and Transplantation Unit Hospital Paul Brousse Villejuif France

Department of Hepatology and Liver Transplantation Royal Free Hospital London UK

Department of HPB Surgery and Liver Transplantation Leeds Teaching Hospitals NHS Trust Leeds UK

Department of HPB Surgery and Transplantation C H R U de Strasbourg Strasbourg France

Department of HPB surgery and Transplantation Hospital Virgen del Rocio Sevilla Spain

Department of Liver and Biliary Tract Surgery Memorial Hospital Istanbul Turkey

Department of Medical Liver Transplant Unit and Liver Hôpital Henri Mondor Creteil France

Department of Medicine Hospital Universitario Puerta de Hierro Madrid Spain

Department of Surgery and Medical and Surgical Specialties University of Catania Catania Italy

Department of Surgery Division of HPB and Transplant Surgery Erasmus MC Transplant Institute Erasmus MC University Medical Center Rotterdam the Netherlands

Department of Surgery Hôpital Universitaire de Genève Geneve Switzerland

Department of Surgery Hospital Universitari de Bellvitge Barcelona Spain

Department of Surgery Kent Hospital Izmir Turkey

Department of Surgery Liver Transplant Institute Turgut Özal Medical Center Malatya Turkey

Department of Surgery Sahlgrenska University Hospital Gothenburg Sweden

Department of Surgery Universitätsklinikum Hamburg Eppendorf Hamburg Germany

Department of Surgery University of Medicine Carol Davila Bucharest Romania

Department of Transplantation Center of cardiovascular surgery and transplantations Brno Czech Republic

Department of Transplantation Minsk Scientific and Practical Center for Surgery Transplantology and Hepatology Minsk Belarus

Department of Transplantation Surgery Karolinska University Hospital Huddinge Sweden

Department of Transplantation Surgery Medical University of Vienna Wien Austria

Department of Visceral Transplant and Thoracic Surgery University Hospital Innsbruck Austria

Edinburgh Transplant Center Royal Infirmary of Edinburgh Edinburg UK

General and Liver Transplant Surgery Unit Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy

Institute of Liver Studies King's College Hospital London UK

Liver Unit Cambridge University Hospitals NHS Foundation Trust Cambridge NIHR Biomedical Research Center Cambridge UK

Liver Unit Queen Elizabeth Hospital Birmingham UK

Transplantation and Liver Surgery Unit Helsinki University Hospital Helsinki Finland

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