Clinical Epidemiology and Ageing

Living or Brain-dead Donor Liver Transplantation for Hepatocellular Carcinoma: A Multicenter, Western, Intent-to-treat Cohort Study.

Azoulay D, Audureau E, Bhangui P, Belghiti J, Boillot O, Andreani P, Castaing D, Cherqui D, Irtan S, Calmus Y, Chazouillères O, Soubrane O, Luciani A, Féray C Ann Surg. 2017;266(6):1035-1044.

<p><b>OBJECTIVE: </b>An intent-to-treat analysis of overall survival (ITT-OS) of cirrhotic patients with hepatocellular carcinoma (HCC) listed for living donor liver transplantation (LDLT) or brain-dead donor liver transplantation (BDLT) across 5 French liver transplant (LT) centers.</p><p><b>BACKGROUND: </b>Comparisons of HCC outcomes after LDLT and BDLT measured from time of transplantation have yielded conflicting results.</p><p><b>METHODS: </b>Records from 861 cirrhotic patients with HCC consecutively listed for either LDLT (n = 79) or BDLT (n = 782) from 2000 to 2009 were analyzed for ITT-OS using a Cox model; and tumor recurrence using 2 competitive risk models.</p><p><b>RESULTS: </b>Tumor staging was similar between groups. In total, 162 patients dropped out (20.7%), all from Group BDLT (P < 0.0001). The postoperative mortality rate and the retransplantation rate were similar between LDLT and BDLT. At 5 years, no statistically significant difference was found in ITT-OS between LDLT and BDLT groups (73.2% vs 66.7%; P = 0.062). LDLT waitlist inclusion (hazard ratio: 0.61 (0.39-0.96); P = 0.034) and a time-of-listing MELD score ≥ 25 (hazard ratio: 1.93 (1.15-3.26); P = 0.014) were independent predictors of ITT-OS. Similar 5-year post-LT OS rates (73.2% and 73.0% for Group LDLT and Group BDLT, respectively; P = 0.407) and HCC recurrence rates (10.9% and 11.2% for Group LDLT and Group BDLT, respectively; P = 0.753) were found. Upon explant analysis, tumors exceeding the Milan criteria, macroscopic vascular invasion, and AFP score>2 were independent predictors of recurrence, whereas LT type was not.</p><p><b>CONCLUSIONS: </b>LDLT improves ITT-OS, and it is not a risk factor for tumor recurrence. Therefore, LDLT and BDLT should be equally encouraged in countries where both are available.</p>

MeSH terms: Brain Death; Carcinoma, Hepatocellular; Female; France; Humans; Intention to Treat Analysis; Liver Cirrhosis; Liver Neoplasms; Liver Transplantation; Living Donors; Male; Middle Aged; Neoplasm Recurrence, Local; Postoperative Complications; Proportional Hazards Models; Reoperation; Risk Factors; Waiting Lists
DOI: 10.1097/SLA.0000000000001986