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Patterns and Predictors of Mortality After Waitlist Dropout of Patients With Hepatocellular Carcinoma Awaiting Liver Transplantation

Gorgen, Andre MD1,2; Rosales, Roizar MD1; Sadler, Erin MD2; Beecroft, Robert MD3; Knox, Jennifer MSc, MD4; Dawson, Laura A. MD5; Ghanekar, Anand PhD, MD1,2; Grant, David MD1,2; Greig, Paul D. MD1,2; Sapisochin, Gonzalo MD1,2

doi: 10.1097/TP.0000000000002616
Original Clinical Science–Liver
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Background. There is a lack of information about survival after dropout from the liver transplant waiting list. Therefore, we aimed to assess the overall survival, and risk factors for death, after waiting list dropout due to hepatocellular carcinoma (HCC) progression.

Methods. We assessed patients who dropped out of the liver transplant waiting list between 2000 and 2016 in a single, large academic North American center. Patients were divided into 3 groups according to the types of HCC progression: locally advanced disease (LAD), extrahepatic disease (EHD), and macrovascular invasion (MVI). The primary outcome was overall survival. Survival was assessed by the Kaplan-Meier method. Predictors of death after dropout were assessed by multivariable Cox regression.

Results. During the study period, 172 patients dropped out due to HCC progression. Of those, 37 (21.5%), 74 (43%), and 61 (35.5%) dropped out due to LAD, EHD, and MVI, respectively. Median survival according to cause of dropout (LAD, EHD, or MVI) was 1.0, 4.4, or 3.3 months, respectively (P = 0.01). Model for End-stage Liver Disease (MELD) score (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.01-1.08), alcoholic liver disease (HR, 1.66; 95% CI, 1.02-2.71), and α-fetoprotein >1000 ng/mL (HR, 1.86; 95% CI, 1.22-2.84) were predictors of mortality after dropout. Dropout due to EHD (HR, 0.61; 95% CI, 0.38-0.98) and undergoing treatment after dropout were protective factors (HR, 0.32; 95% CI, 0.21-0.48) for death.

Conclusions. Patient prognosis after dropout is dismal. However, a subgroup of patients may have longer survival. The present study identifies the patterns of waitlist dropout in patients with HCC and provides evidence for the effectiveness of treatment strategies offered to HCC patients after dropout.

1 Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada.

2 Department of General Surgery, University of Toronto, Toronto, ON, Canada.

3 Joint Department of Imaging, Division of Interventional Radiology, University Health Network, University of Toronto, Toronto, ON, Canada.

4 Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada.

5 Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.

Received 28 August 2018. Revision received 10 December 2018.

Accepted 4 January 2019.

The authors declare no funding or conflicts of interest.

A.G. and R.R. contributed equally to this work.

All authors provided final approval of the manuscript. G.S., J.K., L.A.D., A.G., D.G., and P.D.G. contributed to the conception of the work, the acquisition and interpretation of the data, provided critical revisions to subsequent versions of the manuscript, and approved the final submitted version. E.S. contributed to the acquisition and interpretation of the data for the work and approved the final version. A.G. and R.R. contributed with the data acquisition, performed the data analysis, drafted the first version of manuscript, and approved the final submitted version.

Correspondence: Gonzalo Sapisochin, MD, HBP and Multi Organ Transplant Program, Division of General Surgery, University Health Network, University of Toronto, 585 University Avenue, 11PMB184, Toronto, ON M5G 2N2, Canada. (gonzalo.sapisochin@uhn.ca).

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