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Burra P, Giannini EG, Caraceni P, Ginanni Corradini S, Rendina M, Volpes R, Toniutto P. Specific issues concerning the management of patients on the waiting list and after liver transplantation. Liver Int 2018; 38:1338-1362. [PMID: 29637743 DOI: 10.1111/liv.13755] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/27/2018] [Indexed: 02/06/2023]
Abstract
The present document is a second contribution collecting the recommendations of an expert panel of transplant hepatologists appointed by the Italian Association for the Study of the Liver (AISF) concerning the management of certain aspects of liver transplantation, including: the issue of prompt referral; the management of difficult candidates; malnutrition; living related liver transplants; hepatocellular carcinoma; and the role of direct acting antiviral agents before and after transplantation. The statements on each topic were approved by participants at the AISF Transplant Hepatology Expert Meeting organized by the Permanent Liver Transplant Commission in Mondello on 12-13 May 2017. They are graded according to the GRADE grading system.
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Affiliation(s)
- Patrizia Burra
- Multivisceral Transplant Unit, University Hospital, Padova, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | | | - Riccardo Volpes
- Hepatology and Gastroenterology Unit, ISMETT-IRCCS, Palermo, Italy
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Abstract
Over the last several years, liver transplantation has evolved to become a widely used treatment for hepatocellular carcinoma (HCC). The criteria used were developed in order to have acceptable outcomes for transplant with survival similar to other indications for transplant. These criteria are discussed in detail along with alternate options, including surgical resection and downstaging of HCC in cirrhotics. Technical considerations of liver transplantation must be considered, and living donor liver transplant is a possibility for treatment.
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Affiliation(s)
- Jennifer Berumen
- Department of Surgery, University of California, San Diego, 9300 Campus Point Dr, MC 7745, La Jolla, CA, 92037, USA.
| | - Alan Hemming
- Department of Surgery, University of California, San Diego, 9300 Campus Point Dr, MC 7745, La Jolla, CA, 92037, USA
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Kim Y, Stahl CC, Makramalla A, Olowokure OO, Ristagno RL, Dhar VK, Schoech MR, Chadalavada S, Latif T, Kharofa J, Bari K, Shah SA. Downstaging therapy followed by liver transplantation for hepatocellular carcinoma beyond Milan criteria. Surgery 2017; 162:1250-1258. [PMID: 29033224 DOI: 10.1016/j.surg.2017.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/03/2017] [Accepted: 08/16/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Orthotopic liver transplantation is a curative treatment for hepatocellular carcinoma within Milan criteria, but these criteria preclude many patients from transplant candidacy. Recent studies have demonstrated that downstaging therapy can reduce tumor burden to meet conventional criteria. The present study reports a single-center experience with tumor downstaging and its effects on post-orthotopic liver transplantation outcomes. METHODS All patients with hepatocellular carcinoma who were evaluated by our multidisciplinary liver services team from 2012 to 2016 were identified (N = 214). Orthotopic liver transplantation candidates presenting outside of Milan criteria at initial radiographic diagnosis and/or an initial alpha-fetoprotein >400 ng/mL were categorized as at high risk for tumor recurrence and post-transplant mortality. RESULTS Of the 214 patients newly diagnosed with hepatocellular carcinoma, 73 (34.1%) eventually underwent orthotopic liver transplantation. The majority of patients who did not undergo orthotopic liver transplantation were deceased or lost to follow-up (47.5%), with 14 of 141 (9.9%) currently listed for transplantation. Among transplanted patients, 21 of 73 (28.8%) were considered high-risk candidates. All 21 patients were downstaged to within Milan criteria with an alpha-fetoprotein <400 ng/mL before orthotopic liver transplantation, through locoregional therapies. Recurrence of hepatocellular carcinoma was higher but acceptable between downstaged high-risk and traditional candidates (9.5% vs 1.9%; P > .05) at a median follow-up period of 17 months. Downstaged high-risk candidates had a similar overall survival compared with those transplanted within Milan criteria (log-rank P > .05). CONCLUSIONS In highly selected cases, patients with hepatocellular carcinoma outside of traditional criteria for orthotopic liver transplantation may undergo downstaging therapy in a multidisciplinary fashion with excellent post-transplant outcomes. These data support an aggressive downstaging approach for selected patients who would otherwise be deemed ineligible for transplantation.
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Affiliation(s)
- Young Kim
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Christopher C Stahl
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Abouelmagd Makramalla
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Radiology, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Olugbenga O Olowokure
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Medicine, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Ross L Ristagno
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Radiology, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Vikrom K Dhar
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Michael R Schoech
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Medicine, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Seetharam Chadalavada
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Radiology, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Tahir Latif
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Medicine, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Jordan Kharofa
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Khurram Bari
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Medicine, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Shimul A Shah
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH.
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Wei Q, Gao F, Zhuang R, Ling Q, Ke Q, Wu J, Shen T, Zhang M, Zhang M, Xu X, Zheng S. A national report from China Liver Transplant Registry: steroid avoidance after liver transplantation for hepatocellular carcinoma. Chin J Cancer Res 2017; 29:426-437. [PMID: 29142462 DOI: 10.21147/j.issn.1000-9604.2017.05.07] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective We aimed to evaluate the efficacy and safety of steroid-free immunosuppression after liver transplantation (LT) for hepatocellular carcinoma (HCC). Methods We retrospectively analyzed HCC recipients without steroids after LT (SF group, n=368) based on the China Liver Transplant Registry (CLTR) database. These recipients were matched 1:2 with patients using steroids (S group, n=736) for the same period after LT for HCC, according to propensity scores. Results Multivariate analysis indicates that recipients with younger age [odds ratio (OR), 1.053; P=0.011], preoperative hepatitis B virus (HBV) DNA ≥1,000 copies/mL (OR, 2.597; P=0.004) and beyond Milan criteria (OR, 4.255; P<0.001) were identified as the risk factors associated with tumor recurrence in steroid avoidance recipients after LT. The patients fulfilling the Milan criteria in the SF group presented higher overall and tumor-free survival rates than those in the S group (P<0.05). Multivariate analysis revealed that recipient beyond Milan criteria was an independent prognostic factor for overall survival (OR, 1.690; P<0.001) and tumor-free survival (OR, 2.066; P<0.001). The incidences of new-onset diabetes mellitus (21.20%vs. 33.29%, P<0.001), new-onset hypertension (10.05%vs. 18.61%, P<0.001) and hyperlipidemia (4.08%vs. 7.20%, P=0.042) were significantly lower in the SF group. Conclusions Steroid-free immunosuppression could be safe and feasible for HBV-related HCC patients in LT. Age, HBV DNA level and Milan criteria maybe risk factors associated with tumor recurrence in steroid avoidance recipients. Recipient beyond Milan criteria was an independent prognostic factor and recipient fulfilling Milan criteria can benefit the most from steroid-free immunosuppression.
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Affiliation(s)
- Qiang Wei
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Feng Gao
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Runzhou Zhuang
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Qi Ling
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Qinghong Ke
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jian Wu
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Tian Shen
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Mangli Zhang
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Min Zhang
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Xiao Xu
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou 310003, China
| | - Shusen Zheng
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou 310003, China
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