Analysis of Survival Benefits of Living Versus Deceased Donor Liver Transplant in High Model for End-Stage Liver Disease and Hepatorenal Syndrome.

BACKGROUND AND AIMS: Previous recommendations 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 AND RESULTS: Patients who were listed with MELD > 25 from 2008 to 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 (DDLT) group. ITT-overall survival (OS) was analyzed from the time of listing. Three hundred twenty-five 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), whereas the transplant rate was higher in the ITT-LDLT group (78.3% vs. 52.2%, P < 0.001). The 5-year ITT-OS was superior in the ITT-LDLT group (72.6% vs. 49.5%, P < 0.001) for patients with MELD > 25 and patients with both MELD > 25 and HRS (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 patients with MELD > 25 (88% vs. 85.4%, P = 0.279) and patients with both MELD > 25 and HRS (77% vs. 76.4%, P = 0.701) after LDLT and DDLT, respectively. The LDLT group has a higher rate of renal recovery by 1 month (77.4% vs. 59.1%, P = 0.003) and 3 months (86.1% vs, 74.5%, P = 0.029), whereas the long-term estimated glomerular filtration rate (eGFR) was similar between the 2 groups. ITT-LDLT reduced the hazard of mortality (hazard ratio = 0.387-0.552) across all MELD strata. CONCLUSIONS: The ITT-LDLT reduced waitlist mortality and allowed an earlier access to transplant. LDLT in patients with high MELD/HRS was feasible, and they had similar perioperative outcomes and better renal recovery, whereas the long-term survival and eGFR were comparable with DDLT. LDLT should be considered for patients with high MELD/HRS, and the application of LDLT should not be restricted with a MELD cutoff.

Adjuvant chemotherapy improves oncological outcomes of resectable intrahepatic cholangiocarcinoma: A meta-analysis.

OBJECTIVE: To define the role of adjuvant chemotherapy in the management of resectable intrahepatic cholangiocarcinoma (ICC) by performing a meta-analysis. SUMMARY BACKGROUND DATA: Oncological benefit of adjuvant chemotherapy in resectable ICC remains controversial, high-level evidence in such context is lacking. METHOD: A comprehensive search using Pubmed, EMbase, and Web of Science was performed from inception to October 2018. Studies compared the survival of patients receiving adjuvant chemotherapy versus surgery alone were included. Data were analyzed using random effect model. Quality of each study and presence of publication bias were assessed by Newcastle-Ottawa score (NOS) and funnel plot with Egger test respectively. RESULTS: The present meta-analysis included 15 studies (all were retrospective series) and 5060 patients. Adjuvant chemotherapy was administered either intravenously or intra-arterially in the form of trans-arterial chemo-embolization (TACE). The average NOS for the included studies was 6.5. Pooled analysis of the included studies demonstrated significant advantage in the adjuvant chemotherapy group (HR 0.66, 0.55-079, P <.001, I-square [I] = 20.8%). After 2 studies were removed for heterogeneity, advantage of adjuvant chemotherapy remained (HR 0.72, 0.62-0.84, P <.001, I = 0%). Funnel plot suggested no significant publication bias (Egger test, 2-tailed P = .203). Subgroup analyses suggested that intravenous route of chemotherapy injection (P <.001) and use of gemcitabine base regimen (P = .004) are associated with improved overall survival. Adjuvant chemotherapy did not improve disease-free survival in subgroup analysis (P = .94). CONCLUSION: Adjuvant chemotherapy is associated with improved overall survival and should be considered in patients with ICC following curative resection and in particular to patients with advance disease.