Highlights
- •Increasing tumour burden, alpha-fetoprotein, Child-Pugh, and model for end-stage liver disease score predict HCC wait-list dropout.
- •Novel HCC dropout risk score stratifies 1-year dropout risk from 7% up to 40%.
- •Patients with HCC with the highest dropout risk score >30 have poor transplant survival.
- •In all others with HCC, calculated dropout risk can safely guide wait-list priority.
Background & Aims
It has been suggested that patients with hepatocellular carcinoma (HCC) at high risk
of wait-list dropout would have done poorly after liver transplantation (LT) because
of tumour aggressiveness. To test this hypothesis, we analysed risk of wait-list dropout
among patients with HCC in long-wait regions (LWRs) to create a dropout risk score,
and applied this score in short (SWRs) and mid-wait regions (MWRs) to evaluate post-LT
outcomes. We sought to identify a threshold in dropout risk that predicts worse post-LT
outcome.
Methods
Using the United Network for Organ Sharing database, including all patients with T2
HCC receiving priority listing from 2010 to 2014, a dropout risk score was created
from a developmental cohort of 2,092 patients in LWRs, and tested in a validation
cohort of 1,735 patients in SWRs and 2,894 patients in MWRs.
Results
On multivariable analysis, 1 tumour (3.1–5 cm) or 2–3 tumours, alpha-fetoprotein (AFP)
>20 ng/ml, and increasing Child-Pugh and model for end-stage liver disease-sodium
scores significantly predicted wait-list dropout. A dropout risk score using these
4 variables (C-statistic 0.74) was able to stratify 1-year cumulative incidence of
dropout from 7.1% with a score ≤7 to 39.5% with a score >23. Patients with a dropout
risk score >30 had 5-year post-LT survival of 60.1% vs. 71.8% for those with a score ≤30 (p = 0.004). There were no significant differences in post-LT survival below this threshold.
Conclusions
This study provided evidence that patients with HCC with the highest dropout risk
have aggressive tumour biology that would also result in poor post-LT outcomes when
transplanted quickly. Below this threshold risk score of ≤30, priority status for
organ allocation could be stratified based on the predicted risks of wait-list dropout
without significant differences in post-LT survival.
Lay summary
Prioritising patients with hepatocellular carcinoma for liver transplant based on
risk of wait-list dropout has been considered but may lead to inferior post-transplant
survival. In this study of nearly 7,000 patients, we created a threshold dropout risk
score based on tumour and liver-related factors beyond which patients with hepatocellular
carcinoma will likely have poor post-liver transplant outcomes (60% at 5 years). For
patients below this risk score threshold, priority status could be stratified based
on the predicted risk of wait-list dropout without compromising post-transplant survival.
Graphical abstract
Graphical Abstract
Keywords
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Article info
Publication history
Published online: November 11, 2020
Accepted:
October 29,
2020
Received in revised form:
October 8,
2020
Received:
May 28,
2020
Identification
Copyright
© 2020 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
