Use Live Donors for Liver Transplants for HCC Patients

For some patients with hepatocellular cancer (HCC), a liver transplant is the best treatment.

But there is a long waiting list for all organ transplants.

A new study shows that outcomes with liver transplants from live donors are better than outcomes with transplants from deceased donors, leading to calls for increasing the availability of live donation.

“Transplant programs worldwide should be encouraged to expand their live donor programs to manage patients with HCC,” suggest authors of the new study, published in September in JAMA Surgery.

The findings are important in light of the fact that among patients with HCC, liver transplants are restricted to those patients who have the highest chances of survival, owing to long donor organ waiting lists, say the authors. Use of transplants from living donors could increase the availability of organs for patients on the deceased donor waiting list.

“One could even argue that a living donor gives two organs back to the organ pool,” the authors comment.

“Efforts to expand the donor pool through living donor liver transplant for patients with HCC will ultimately increase the number of available deceased donor liver transplants to help all patients in need of liver transplant,” David A Gerber, MD, of the University of North Carolina at Chapel Hill, and colleagues write in an accompanying commentary.

“It is very important that donors aren’t recruited or solicited, but with the growth of transplant programs, more potential donors will become aware of this opportunity and will step forward seeking to help someone else,” Gerber commented to Medscape Medical News.

Live Liver Donor = Lower Death Risk

The new study was conducted by first author Quirino Laid, MD, PhD, of the Department of General Surgery and Organ Transplantation, Sapienza University, Rome, Italy, and colleagues. They explain that the need to better understand the potential benefits of living donor organs is pressing. Liver cancer rates continue to rise, and the demand for organs outpaces the supply. Although various smaller studies have shown survival benefits of live donor liver transplant for people with HCC, debate continues. Previous evidence has suggested higher cancer recurrence rates and unfavorable outcomes.

The multicenter study is thought to be the largest to date on this issue. The investigators evaluated data from patients who were on liver donation waiting lists for a first transplant between January 2000 and December 2017. The study included two cohorts of patients on waiting lists: an international cohort, consisting of 3052 patients at 12 collaborative transplant centers in Europe, Asia, and the United States; and a Canadian cohort, consisting of 906 patients.

The majority of patients were men (80.2%). The median age at the time of first referral was 58 years.

About a third of patients (33.1%) in the international cohort and slightly fewer than a third (27%) in the Canadian cohort received live donor liver transplants; the reminder received liver transplants from deceased donors.

The median follow-up period was 3.3 years. Receiving a live donor liver transplant was independently associated with a 49% reduction in the overall risk for death (hazard ratio [HR], 0.51) in the international cohort and a 43% reduction in the Canadian cohort (HR, 0.57; both P < .001).

After adjustment for potential confounders, living donor liver transplantation remained independently associated with a reduced the risk for overall death. There was a reduction of 33% in the international cohort (P = .001) and a reduction of 48% in the Canadian cohort (P < .001).

“Divergent experiences all converged to a similar 40% to 50% reduction in intention-to-treat death risk,” the authors write.

Importantly, there were no increases in post-transplant cancer recurrence rates in the live donor groups in either cohort. Rates ranged from 13% to 16% over 5 years and from 17% to 22% after 10 years in both groups.

The median amount of time on the waiting list was significantly shorter for patients in the live donor group than for those in the deceased donor group (1 month vs 6 months in the international cohort [P < .001]; 5 months vs 6 months in the Canadian cohort [P = .006]).

Notably, in the deceased donor groups, there were 295 dropouts, compared with no dropouts among the live donor patients in the international cohort (P < .001). In the Canadian cohort, the corresponding rates were 32.2% and 13.9% (P < .001).

Diverse Transplant Centers, Larger Cohorts Set Study Apart

Although these latest results are consistent with those of recent studies conducted in France, Hong Kong, and elsewhere, in the current study, the cohorts were larger, say the authors.

“Compared with previous studies, all of which were based on relatively small case series, the present study examined the data of almost 4,000 patients who were on a waiting list for a transplant; therefore, this study may be the largest cohort study on this topic,” they point out.

In addition to improved timing of a transplant, other factors, such as patient selection, help explain the better survival, editorialist Gerber commented to Medscape Medical News.

“Survival improvement [with live donor liver transplants] is a combination of [surgeon] experience in this transplant procedure and an appropriate selection bias, meaning taking patients who aren’t too sick while waiting on the transplant but who would benefit from the operation,” he said.

Gaining that experience may be particulalry challenging in the United States, owing to regulatory barriers to expanding the programs, but efforts to overcome that are moving ahead, Gerber added.

“This issue of where an individual gains the experience or expertise is being discussed as transplantation has grown worldwide,” he notes.

As programs expand, the availability of live liver donors should improve, he suggested.

In a related story, Medscape recently reported on the controversial issue of liver transplant as an option for the treatment of liver metastases resulting from colorectal cancer.

Study co-author Gonzalo Sapisochin, MD, has received grants from Bayer and Roche outside the submitted work as well as personal fees from Integra, Novartis, and AstraZeneca. No other relevant financial relationships were reported.

JAMA Surgery. Published online July 14, 2021. Abstract, Commentary

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