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Abstract Details
Analysis of survival benefits of living vs. deceased donor liver transplant in high MELD and hepatorenal syndrome
Hepatology. 2020 Oct 2. doi: 10.1002/hep.31584. Online ahead of print.
Tiffany Cho-Lam Wong12, James Yan-Yue Fung34, Herbert H Pang5, Calvin Ka-Lam Leung1, Hoi-Fan Li1, Sui-Ling Sin12, Ka-Wing Ma12, Brian Wong-Hoi She12, Jeff Wing-Chiu Dai12, Albert Chi-Yan Chan12, Tan-To Cheung12, Chung-Mau Lo12
Author information
1Department of Surgery, The University of Hong Kong, Hong Kong, China.
2Department of Surgery, Queen Mary Hospital, Hong Kong, China.
3Department of Medicine, The University of Hong Kong, Hong Kong, China.
4Department of Medicine, Queen Mary Hospital, Hong Kong, China.
5School of Public Health, The University of Hong Kong, Hong Kong, China.
Abstract
Background & aims: Previous recommendation suggested living donor liver transplantation(LDLT) should not be considered for patients with Model for End-stage Liver Disease(MELD)>25 and hepatorenal syndrome(HRS).
Approach & results: Patients who were listed with MELD>25 from 2008-2017 were analyzed with intention-to-treat(ITT) basis retrospectively. Patients who had a potential live donor were analyzed as ITT-LDLT whereas those who had none belonged to ITT-deceased donor liver transplantation(ITT-DDLT)group. ITT-overall survival(ITT-OS) was analyzed from the time of listing. 325 patients were listed(ITT-LDLT n=212, ITT-DDLT n=113). The risk of delist/death was lower in the ITT-LDLT group(43.4% vs. 19.8%,P<0.001)while transplant rate was higher in the ITT-LDLT group(78.3% vs. 52.2%,P<0.001). The 5-year ITT-OS were superior in the ITT-LDLT group(72.6% vs. 49.5%,P<0.001) for MELD>25, and for MELD>25 and HRS patients(56% vs. 33.8%,P<0.001). Waitlist mortality was the highest early after listing and the distinct alteration of slope at survival curve showed that the benefits of ITT-LDLT occurred within the first month after listing. Perioperative outcomes and 5-year patient survival were comparable for MELD>25(88% vs. 85.4%,P=0.279) and MELD>25 and HRS patients(77% vs. 76.4%,P=0.701) after LDLT and DDLT respectively. LDLT group has a higher rate of renal recovery by 1-month(77.4% vs. 59.1%,P=0.003) and by 3-month(86.1% vs, 74.5%,P=0.029) while the long-term eGFR was similar between the 2 groups. ITT-LDLT reduced the hazard of mortality(HR=0.387-0.552)across all MELD strata.
Conclusions: The ITT-LDLT reduced waitlist mortality and allowed an earlier access to transplant. LDLT in high MELD/HRS patients were feasible, they had similar perioperative outcomes and better renal recovery, while the long-term survival and eGFR were comparable to DDLT. LDLT should be considered for high MELD/HRS patients and the application of LDLT should not be restricted with a MELD cut-off.