Liver transplantation for hepatocellular carcinoma with live donors or extended criteria donors: a propensity score-matched comparison

Background To compare patient survival after liver transplantation (LT) for hepatocellular carcinoma (HCC) from live donors (LD) or extended criteria donors (ECD). Methods Data from consecutive LT procedures for HCC involving either LD or ECD were reviewed. Patient survival was our primary outcome. Re-transplantation (Re-LT), ischemic type bile lesions (ITBL), and tumor recurrence represented secondary outcomes. The primary outcome was statistically analyzed using Kaplan-Meier estimates and Cox proportional hazards regression; logistic regression analyses were used for statistical analysis of the secondary outcomes. Propensity score was calculated based on patient age, sex, hepatitis C viral infection (HCV), laboratory model for end-stage liver disease (labMELD) score, bridging treatment, Milan criteria, alpha-fetoprotein levels, and tumor grade. Results The study evaluated 109 recipients undergoing LT from either LD (n=57) or ECD (n=52). LT procedure (hazard ratio [HR] 2.349, 95% confidence interval [CI] 1.151-4.794, P=0.0190), age (HR 1.075, 95% CI 1.020-1.133, P=0.0074) and labMELD score (HR 1.082, 95% CI 1.021-1.147, P=0.0075) reached significance by Cox proportional hazards regression. After adjustment with the propensity score (stratification with 5 strata), the LT procedure was still significant (HR 2.401, 95% CI 1.114-5.175, P=0.0253). Tumor grade (odds ratio [OR] 9.628, 95% CI 1.120-82.752, P=0.0391), labMELD score (OR 1.224, 95% CI 1.019-1.471, P=0.0306), and Milan criteria (OR 6.375, 95% CI 1.239-32.796, P=0.0267) gained statistical significance by logistic regression analysis for Re-LT, ITBL, and tumor recurrence, respectively. Conclusions LT for HCC showed superior patient survival with ECD rather than LD grafts. Re-LT, ITBL, and tumor recurrence showed no significant differences between the two groups. However, the diverging criteria for the definition of ECD grafts represent a considerable limitation for the wide application of this policy.