The role and limitation of living donor liver transplantation for hepatocellular carcinoma

Abstract

Liver transplantation for hepatocellular carcinoma (HCC) is restricted by the scarcity of cadaver grafts. Living donor liver transplantation (LDLT) may potentially increase the applicability but its role and limitation are not clear. We studied the outcome of a cohort of 51 patients with unresectable HCC who were accepted on list for both options of deceased donor liver transplantation (DDLT) and LDLT. Twenty-five of 51 (49%) patients had voluntary living donors (group 1) and 26 did not (group 2). Patients in group 1 were younger, and more often had a MELD score more than 20 or blood group other than O. Twenty-one patients of group 1 underwent LDLT after a median waiting time of 24 days (range, 2-126 days), but 4 did not because the donors were not suitable (HBsAg-positive, 2; ABO-incompatible, 1; liver dysfunction, 1). Of the 30 patients who remained on list, only 6 underwent DDLT after a median waiting time of 344 days (range, 22-1359 days, P < .005). Nineteen died before transplantation and 2 were alive but taken off the list because of disease progression (drop-out rate, 70%). One patient was alive on list and 2 had undergone transplantation outside Hong Kong. The 1-, 2-, 3-, and 4-year intention-to-treat survival rates were 88%, 76%, 66%, and 66%, respectively, for group 1 and 72%, 46%, 38%, and 31%, respectively, for group 2 (relative risk of death for group 1, 0.35; 95% CI, 0.14 to 0.90; P ‫؍‬ .029). In conclusion, although complicated factors such as donor voluntarism and selection criteria limit the role of LDLT for HCC, LDLT allows more patients to undergo early transplantation and results in a better outcome. L iver transplantation offers the best chance of cure for unresectable hepatocellular carcinoma (HCC), 1-3 but the scarcity of cadaver liver grafts has seriously limited its role. To justify organ allocation, candidacy is restricted only to patients with early tumors who fulfill strict selection criteria 1,4 so that the survival is comparable to that with non-neoplastic disease. Unfortunately, the prolonged waiting time results in drop-outs because of tumor progression and adversely affects the outcome of these patients. 5,6 In addition, the unpredictable timing of a deceased donor graft makes it difficult if not impossible to accurately stage the disease and to plan any study for neoadjuvant therapy before transplantation.With the recent advances in adult living donor liver transplantation (LDLT), [7][8][9] there is potentially a drastic change in the role of liver transplantation. Studies on hypothetical decision analytic models 10,11 have demonstrated the theoretical survival benefit of LDLT over deceased donor liver transplantation (DDLT) which depends largely on the waiting time and drop-out rate. In parts of Asia including Hong Kong where there is a high incidence of HCC and a low deceased donor rate, LDLT is likely to generate a great benefit. Nonetheless, although LDLT is not restricted by the system of deceased donor organ allocation and waiting time, many other factors such as donor vol...

Donor quality of life before and after adult-to-adult right liver live donor liver transplantation

“…37 This has to be interpreted with current opinions 37,38 and local results. 39 Continuity of care by the same team of surgeons is logical. 40 Donor feasibility has to be made in concert with the physical condition of the recipient in terms of graft size for recipients with portal hypertension.…”

Liver Transplantation for Hepatocellular Carcinoma in Asia

“…The role of LDLT and its intention-to-treat survival benefit over DDLT in patients with early HCC have been confirmed in clinical series [53], but several observations have emerged that warrant caution in assuming that the advantage of LDLT is as predicted by hypothetical studies. First, the process of waiting for a living donor is comparable with that of waiting for a deceased donor graft.…”

“…While the availability of a deceased donor graft depends on a system of organ allocation, the availability of a living donor depends on the family members' voluntarism and the donor selection criteria. A clinical series from Hong Kong showed that Ͼ50% of patients with early HCC might not have a suitable voluntary donor [53]. Second, several recent studies have reported a tendency toward a higher rate of recurrence and lower rate of survival after LDLT for HCC.…”

Percutaneous radiofrequency ablation of hepatocellular carcinoma as a bridge to liver transplantation

“…7,8 This pressure has driven the increased use of living and marginal donors as well as split cadaveric transplantations. [9][10][11][12] Also of concern is whether any increase in tumor burden, even below the current limits warranting removal from transplant candidacy, might adversely affect posttransplantation prognosis.…”