Performance of pre-transplant criteria in prediction of hepatocellular carcinoma progression and waitlist dropout.

BACKGROUND & AIM: Liver transplantation (LT) selection models for hepatocellular carcinoma (HCC) have not been proposed to predict waitlist dropout because of tumour progression. The aim of this study was to compare the alpha-foetoprotein (AFP) model and other pre-LT models in their prediction of HCC dropout. METHODS: A multicentre cohort study was conducted in 20 Latin American transplant centres, including 994 listed patients for LT with HCC from 2012 to 2018. Longitudinal tumour characteristics, and patterns of progression were recorded at time of listing, after treatments and at last follow-up over the waitlist period. Competing risk regression models were performed, and model's discrimination was compared estimating Harrell's adapted c-statistics. RESULTS: HCC dropout rate was significantly higher in patients beyond (24% [95% CI 16-28]) compared to those within Milan criteria (8% [95% IC 5%-12%]; p < .0001), with a SHR of 3.01 [95% CI 2.03-4.47]), adjusted for waiting list time and bridging therapies (c-index 0.63 [95% CI 0.57; 0.69). HCC dropout rates were higher in patients with AFP scores >2 (adjusted SHR of 3.17 [CI 2.13-4.71]), c-index of 0.71 (95% CI 0.65-0.77; p = .09 vs Milan). Similar discrimination power for HCC dropout was observed between the AFP score and the Metroticket 2.0 model. In patients within Milan, an AFP score >2 points discriminated two populations with a higher risk of HCC dropout (SHR 1.68 [95% CI 1.08-2.61]). CONCLUSIONS: Pre-transplant selection models similarly predicted HCC dropout. However, the AFP model can discriminate a higher risk of dropout among patients within Milan criteria.

Direct-Acting Antivirals and Hepatocellular Carcinoma: No Evidence of Higher Wait-List Progression or Posttransplant Recurrence.

The association between direct-acting antivirals (DAAs) and hepatocellular carcinoma (HCC) wait-list progression or its recurrence following liver transplantation (LT) remains uncertain. We evaluated the impact of DAAs on HCC wait-list progression and post-LT recurrence. This Latin American multicenter retrospective cohort study included HCC patients listed for LT between 2012 and 2018. Patients were grouped according to etiology of liver disease: hepatitis C virus (HCV) negative, HCV+ never treated with DAAs, and HCV+ treated with DAAs either before or after transplantation. Multivariate competing risks models were conducted for both HCC wait-list progression adjusted by a propensity score matching (pre-LT DAA effect) and for post-LT HCC recurrence (pre- or post-LT DAA effect). From 994 included patients, 50.6% were HCV-, 32.9% were HCV+ never treated with DAAs, and 16.5% were HCV+ treated with DAAs either before (n = 66) or after LT (n = 98). Patients treated with DAAs before LT presented similar cumulative incidence of wait-list tumor progression when compared with those patients who were HCV+ without DAAs (26.2% versus 26.9%; P = 0.47) and a similar HCC-related dropout rate (12.1% [95% CI, 0.4%-8.1%] versus 12.9% [95% CI, 3.8%-27.2%]), adjusted for baseline tumor burden, alpha-fetoprotein values, HCC diagnosis after listing, bridging therapies, and by the probability of having received or not received DAAs through propensity score matching (subhazard ratio [SHR], 0.9; 95% CI, 0.6-1.6; P = 0.95). A lower incidence of posttransplant HCC recurrence among HCV+ patients who were treated with pre- or post-LT DAAs was observed (SHR, 0.7%; 95% CI, 0.2%-4.0%). However, this effect was confounded by the time to DAA initiation after LT. In conclusion, in this multicenter cohort, HCV treatment with DAAs did not appear to be associated with an increased wait-list tumor progression and HCC recurrence after LT.

Predictors of mortality in patients on the waiting list for liver transplantation / Los predictores de mortalidad en pacientes en lista de espera para trasplante hepático

Background and aim: The demand for liver transplantation (LTx) increases every year, which is in contrast to the stagnation in the number of donors. This phenomenon has given rise to longer waiting times, which results in higher pre-transplantation mortality. Thus, our aim for this study was to identify risk factors, including nutritional variables, for mortality for patients who are on the waiting list for LTx. Methods: Patients on the waiting list were assessed to identify risk factors for mortality. Data related to demographic, socioeconomic, and etiologic factors, liver disease severity, complications, medications, and biochemical tests related to disease, nutritional status, diet intake, and physical activity were collected. Results: There were 159 patients followed, and 47.8% (76) were transplanted. The mortality rate while on the waiting list was 25.7% patient-years, and 40 patients died (28.0%). Variables associated with mortality during this period (p < 0.05) were the following: severe malnutrition (OR 2.5/CI: 1.2-5.3), low serum sodium values (OR: 1.1/CI: 1.01-1.2), and cryptogenic cirrhosis (OR: 2.2/CI: 1.1-4.6). Conclusions: Special attention should be given to patients with low serum sodium, those who are diagnosed with cryptogenic cirrhosis and the severely malnourished. An early diagnosis of malnutrition and an appropriate nutritional intervention is mandatory in such patients (AU)

Antecedentes y objetivo: La demanda de trasplante de hígado aumenta cada año, lo que está en contraste con el estancamiento en el número de donantes. Este fenómeno ha dado lugar a largos tiempos de espera, lo que resulta en una mayor mortalidad pre-trasplante. Por lo tanto, nuestro objetivo de este estudio fue identificar los factores de riesgo, incluidas las variables nutricionales, para la mortalidad en los pacientes que están en lista de espera para un trasplante de hígado. Métodos: Los pacientes en lista de espera fueron evaluados para identificar los factores de riesgo para la mortalidad. Los datos relacionados con los factores demográficos, socioeconómicos y etiológico, gravedad de la enfermedad hepática, complicaciones, medicamentos y exámenes bioquímicos relacionados con la enfermedad, el estado nutricional, la ingesta de la dieta y la actividad física fueron recogidos. Resultados: Se identificaron 159 pacientes seguidos, y el 47,8% (76) fueron trasplantados. La tasa de mortalidad en lista de espera fue de 25,7% paciente-año, y 40 pacientes fallecieron (28,0%). Las variables asociadas con la mortalidad durante este período (p < 0,05) fueron los siguientes: desnutrición severa (OR 2,5/CI: 1,2 a 5,3), valores bajos de sodio en suero (OR: 1,1/CI: 1,1 a 1,2) y la cirrosis criptogénica (OR: 2,2/CI: 1,1-4,6). Conclusiones: Se debe prestar especial atención a los pacientes con bajo contenido de sodio sérico, los que reciben el diagnóstico de cirrosis criptogénica y la desnutrición severa. El diagnóstico precoz de la malnutrición y la intervención nutricional adecuada es obligatoria en estos pacientes (AU)