Outcomes of Living and Deceased Donor Liver Transplant Recipients With Hepatocellular Carcinoma: Results of the A2ALL Cohort

Abstract

Hepatocellular carcinoma (HCC) represents an increasing fraction of liver transplant indications; the role of living donor liver transplant (LDLT) remains unclear. Recurrence and post-transplant mortality rates were compared in LDLT and deceased donor liver transplant (DDLT) patients with at least one potential living donor evaluated. HCC recurrence and post-transplant mortality were evaluated among 100 LDLT and 97 DDLT recipients in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study. Mortality from date of evaluation of each recipient’s first potential living donor was analyzed. LDLT recipients had shorter time to transplant, were more likely to have tumors exceeding Milan criteria, higher alpha-fetoprotein levels, and less likely to have received pre-operative loco-regional therapy than DDLT recipients. Unadjusted 5-year HCC recurrence was significantly higher after LDLT (38%) than DDLT (11%), (p=0.0004). After adjustment for tumor characteristics, HCC recurrence remained significantly different between LDLT and DDLT recipients (hazard ratio (HR) = 2.35; p=0.04) for the overall cohort but not for recipients transplanted following the introduction of MELD prioritization. Five-year post-transplant survival was similar in LDLT and DDLT recipients from time of transplant (HR=1.32; p=0.27) and from date of LDLT evaluation (HR=0.73; p=0.36). We conclude that the higher recurrence observed after LDLT is likely due to differences in tumor characteristics, pre-transplant HCC management, and waiting time.

Liver transplantation for hepatocellular carcinoma from living-donor vs. deceased donor

“…They suggested that the physiology of the small graft may stimulate tumor recurrence. The results of the A2ALL cohort in USA (20) demonstrated an impaired outcome in LDLT recipients, in which HCC recurrence remained significantly different between LDLT and DDLT after adjustment for tumor characteristics. They concluded that the higher recurrence observed after LDLT UNOS, United Network for Organ Sharing was likely due to differences in the tumor characteristics, pretransplant HCC management, and waiting time between the programs.…”

“…There were ten single-institutional reports (3,10,13-15, 17-19,21,22) and three multi-center reports (16,20,23).…”

Living vs. deceased-donor liver transplantation for patients with hepatocellular carcinoma

“…Although the differences did not reach statistical significance, HCCs in the LDLT group were more likely to have vascular invasion (22% vs. 10%) and include more poorly differentiated tumors (15% vs. 3%) than the DDLT group. In 2012, after accumulation of a significant number of cases, Kullik et al (16) reported updated data on 197 cases (100 LDLT and 97 DDLT). According to this report, the 5-year recurrence rate was significantly higher after LDLT than DDLT, as in their previous report (38% vs. 11%, P=0.0004).…”

“…Therefore, LDLT for patients with HCC is being accepted worldwide as a solution to donor shortage and waiting list mortality (11,12). However, with the accumulation of cases, higher recurrence rates after LDLT in comparison to DDLT have been reported by several authors (13)(14)(15)(16)(17). In this review, we aim to present a current overview of the outcomes of LDLT compared to those of DDLT in patients with HCC, with emphasis on the recurrence of HCC.…”

Liver transplantation in Germany

“…(14) The short waiting time for transplant and excellent graft function are key arguments for living related donors in HCC patients, even though there may be a higher rate of HCC recurrence. (15) In Germany, there is no strict age limit for LT. However, most centers will only accept exceptionally patients above the age of 70 years for LT due to the organ shortage.…”