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Living donor liver transplantation for hepatocellular carcinoma: Altruism to the rescue
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EDITORIAL
Liver Transplantation
Volume 10, Issue 3, Pages 448
Published Online: March 2004
Robert A. Fisher
Liver transplantation for nonresectable Milano/UNOS criteria T1 and T2 liver cancer in end stage liver disease is the indisputable best treatment option for cure and survival. For this select minority of cirrhotic patients with hepatocellular carcinoma (HCC) who are designated an intent to treat group with transplantation, it is death from complications of underlying liver disease and cancer progression before liver graft availability, that prevents optimal life benefit. 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. 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. 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 post-transplant 80% actuarial survival and a 38% intention-to-treat 3-year survival.
The results of this study clearly were not biased by an overly conservative donor selection criteria, or public controversy over equitable organ allocation, or debate of justifying the risks of a living donor for a recipient with an extended HCC indication.
The prevalence of hepatitis B infection in the study community was a predictable and significant negative variable impacting donor availability. The negative impact of the recipient being of O blood group and the positive impact to donor voluntarism of 1/3 of the living donor liver recipients having survived recurrence of HCC after partial hepatectomy was surprising . The authors have made their point, that modeling cannot yet predict the variables that limited voluntary living donor availability to less than 50%, especially in a setting where unique circumstances would have predicted the living donor voluntarism to be higher. No doubt the rate-limiting step of living donor voluntarism will vary from clinical setting and locality. What is predictable is that living donor liver transplantation, in experienced hands, provides an effective, durable, and curative resource for select patients with unresectable hepatocellular carcinoma.
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