Living donor liver transplantation for early hepatocellular carcinoma: A life-expectancy and cost-effectiveness perspective

Abstract

Cadaveric liver transplantation (CLT) is an excellent treatment for early hepatocellular carcinoma (HCC). Its use, however, is limited by the shortage of grafts, with up to 30% of patients developing contraindications to the procedure while waiting for a donor. Living donor liver transplantation (LDLT) has emerged as an alternative to overcome this limitation. We compared the consequences of LDLT versus CLT using a Markov model balancing the gains and losses in life expectancy among donors and recipients. For a 60-yearold recipient with a 70% 5-year survival after transplantation, a 4% monthly drop-out rate, and a donor with 1% mortality, LDLT became more effective than CLT after 3.5 months on the waiting list. These results varied with the probability of developing contraindications to transplantation, the survival after transplantation, and the donor's mortality. For a 12-month delay saved on the waiting list, the gain in survival provided by LDLT compared with CLT ranged between 0 and 2.8 life years depending on survival after transplantation, time spent on the waiting list, and drop-out rate. LDLT was cost-effective (less than $50,000 per quality-adjusted life year saved) in all scenarios of waiting lists exceeding 7 months, and this figure ranged from 2 to 16 months when varying the drop-out rate. LDLT for early HCC offered substantial gains in life expectancy with acceptable cost-effectiveness ratios when the waiting list exceeds 7 months. The gain in life expectancy and the costeffectiveness of LDLT were more dependent on the drop-out rate and the outcome after transplantation than on donor's mortality. (HEPATOLOGY 2001;33:1073-1079.)Liver transplantation is an excellent treatment for early hepatocellular carcinoma (HCC). Theoretically, this procedure is able to cure the tumor and the underlying cirrhosis, and can be applied to patients with end-stage liver disease. Five-year survival rates above 70% with a low tumor recurrence rate are obtained in well selected candidates. [1][2][3][4] In practice, however, the results of cadaveric liver transplantation (CLT) for HCC depend on the time waiting for an organ donor, which commonly exceeds 1 year in many centers, both in Europe and in the United States, with many patients developing contraindications (e.g., tumor spread) and becoming ineligible for the procedure. [5][6][7] In addition, there is an increasing demand for organs due to the worldwide rising incidence of HCC. 8,9 Living donor liver transplantation (LDLT) with a partial liver graft (usually, for an adult, the right half of the liver), has emerged as a possible solution to the shortage of organs. [10][11][12][13][14] LDLT has been performed in the pediatric population with results similar to CLT. Data from adult-to-adult LDLT are still scarce, but short-term figures are equivalent to CLT. [10][11][12][13][14] LDLT has the advantage of decreasing the waiting time before receiving a transplant, thereby eliminating the risk of adverse events related to the waiting list. On the other hand, there are co...

Role of Liver Transplantation for Hepatocellular Carcinoma

“…24 Even in small HCC, LDLT seems to be more effective from a life-expectancy and cost effectiveness viewpoint 25 and certainly both donor and recipient outcomes have improved in the 12 years that have passed since the publication of this analysis. The Mount Sinai group reported outcomes of offering LDLT to patients beyond the Milan criteria.…”

Living donor liver transplantation for hepatocellular carcinoma: Altruism to the rescue

“…3 Outcome modeling of adult to adult living donor liver transplantation for the HCC transplant candidate with the greatest survival advantage, 70% 5-year post-transplant survival, predicted the most significant gains in life expectancy and cost effectiveness when waiting for a deceased donor liver graft exceeded 7 months. 4 The report by Chung-Mau Lo, Sheung-Tat Fan and colleagues of the University of Hong Kong, in this issue of Liver Transplantation, is a retrospective clinical intention-to-treat study of the limitations and benefits of the living donor and recipient liver transplant process for the noncontroversial, greatest curative potential cirrhotic patient with unresectable HCC.The 51 HCC patients listed for transplant in this study, constituted the most highly select, 3.5% of 1438 patients with a diagnosis of HCC; in a clinical setting of one of the highest prevalence of HCC and chronic hepatitis B infection in the world. Simultaneously, the extremely low-cadaver donation rate (12%) made living liver donation the primary and predictably the only chance for expedient liver replacement.…”

“…It is not surprising that previous modeling would not predict the 70% drop-out rate, and a low 46%, 2-year intention-to-treat survival for deceased donor liver transplant in this study. 4 Predictably, 19 patient deaths prior to transplant were from HCC (58%) and complication of underlying cirrhosis (26%).Of the 25 patients with a potential living donor, 84% underwent living donor transplant, at a median 24 days waiting time, with a 3-year post-transplant 81% actuarial survival and a 66% intention-to-treat 3-year survival. Of the 26 patients without a living donor, 20% underwent local deceased donor liver transplant, at a median 344 days waiting time, with a 3-year posttransplant 80% actuarial survival and a 38% intentionto-treat 3-year survival.…”

“…3 Outcome modeling of adult to adult living donor liver transplantation for the HCC transplant candidate with the greatest survival advantage, 70% 5-year post-transplant survival, predicted the most significant gains in life expectancy and cost effectiveness when waiting for a deceased donor liver graft exceeded 7 months. 4 The report by Chung-Mau Lo, Sheung-Tat Fan and colleagues of the University of Hong Kong, in this issue of Liver Transplantation, is a retrospective clinical intention-to-treat study of the limitations and benefits of the living donor and recipient liver transplant process for the noncontroversial, greatest curative potential cirrhotic patient with unresectable HCC.…”

Transplante de fígado no carcinoma hepatocelular: a escassez de órgãos e resultados bem estabelecidos justificariam ampliação das indicações ou de novas modalidades técnicas?

“…Muitos centros usam combinações destas abordagens com o intuito final de cura do CHC, associados ao transplante de fígado (1) . SARASIN et al (11) , baseados no contexto emocional e ético desencadeado pelos transplantes inter vivos, avaliaram o CHC além deste cenário, baseando-se na análise de múltiplas variáveis clínicas que afetariam a evolução do transplante inter vivos. Observaram que 7 meses é o tempo de espera em lista, acima do qual deveria optar-se pelo transplante inter vivos nos cirróticos com CHC.…”