Analysis of survival benefits of living vs. deceased donor liver transplant in high MELD and hepatorenal syndrome.

Wong, Tiffany Cho-Lam; Yan-Yue Fung, James; Pang, Herbert H; Leung, Calvin Ka-Lam; Li, Hoi-Fan; Sin, Sui-Ling; Ma, Ka-Wing; She, Brian Wong-Hoi; Dai, Jeff Wing-Chiu; Chi-Yan Chan, Albert; Cheung, Tan-To; Lo, Chung-Mau

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.