The impact of the donor risk index on tumor free survival in patients undergoing liver transplantation with hepatocellular carcinoma.
Moonka D, Nagai S, Harper A, and Salgia R. The impact of the donor risk index on tumor free survival in patients undergoing liver transplantation with hepatocellular carcinoma. Am J Transplant 2017; 17:433.
Am J Transplant
In this study, we look at the impact of donor quality on tumor free survival in patients undergoing liver transplant (LT) with hepatocellular carcinoma (HCC) using the donor risk index (DRI) and its components. METHODS: We looked at all patients who underwent LT from March, 2002 to June, 2015 listed with the UNOS HCC exception. We excluded living donor recipients (214), multi-organ transplants (259), extrahepatic spread at LT (130) cholangiocarcinoma (79) and those who did not survive three months (585) leaving 16,416 patients. Patients were evaluated for tumor free survival using donor variables including DRI with Kaplan-Meier (KM) curves with log rank tests. Multivariate modeling was done using competing risks regression analysis. Recurrence data was obtained using post-transplant malignancy forms or cause of death data. RESULTS: Of the 16,416 patients transplanted with HCC exception, 2134 or 13.0% experienced HCC recurrence. Patients were divided into tertiles (Groups 1-3) by DRI. Group 1 had 5275 patients with mean DRI of 1.04 + 0.09 (range of 0.77-1.19). Group 2 contained 5610 patients with mean DRI of 1.38 + 0.11 (range of 1.2-1.57) and Group 3 had a mean DRI of 1.88 + 0.26 (range of 1.58-3.62). Three year tumor free survival for the three groups respectively was 89.2%, 88.2% and 87.7% and the difference was significant (P=0.001). On multivariate analysis, DRI remained significant with a HR of 1.21 (CI 1.09-1.34: P=0.003) per 1.0 point of DRI. In a separate multivariate analysis of the DRI components, donor age over 60 years (HR=1.15: CI 1.03-1.27: P=0.022), donor height (HR=0.99 per cm: CI 0.99-0.99: P=0.042) and national and regional sharing (HR=1.14: CI 1.03-1.24: P=0.017) remained significant whereas donor race, CVA as cause of death, cold ishemia time and DCD or split livers were not. CONCLUSIONS: In patients undergoing LT with HCC, decreased donor quality, as determined by the DRI, is associated with decreased tumor free survival. While the difference is significant on KM assessment and multivariate modeling, the numerical difference is small and is less than 2% at three years after LT. Individual variables of the DRI associated with decreased tumor free survival include older donor age, shorter donor height, and national and regional sharing.