Outcomes in Hepatitis C Virus–Infected Recipients of Living Donor vs. Deceased Donor Liver Transplantation

Hepatitis C virus (HCV)–related end-stage liver disease is the leading indication for liver transplantation in the United States. Adult-to-adult living donor liver transplantation represents an important means of expanding the donor pool, making transplantation available to an increasing number of patients on the waiting list. Prior reports of HCV-infected living donor liver transplant (LDLT) recipients having a poorer graft outcome than HCV-infected deceased donor liver transplant (DDLT) recipients have raised concerns regarding this donor option for HCV-infected persons.1-5 In a study of 764 LDLT and 1,470 matched DDLT recipients transplanted between 1998 and 2001, the overall risk of graft failure was 60% higher in LDLT recipients compared to DDLT recipients (hazard ratio [HR] = 1.6; 95% confidence interval, 1.1, 2.5) after adjusting for baseline differences in the groups such as serum creatinine, United Network for Organ Sharing medical urgency status, and need for life support.4 In HCV-positive patients, a similar pattern was seen of significantly lower graft survival in LDLT compared with DDLT recipients. In contrast, a second study from the United Network for Organ Sharing database found no significant difference in the 2-year graft survival between 279 LDLT and 3,955 DDLT recipients transplanted between 1999 and 2002 with a diagnosis of chronic HCV (P = 0.21).5 Several theories have been proposed to explain differences in HCV recurrence in LDLT vs. DDLT recipients. The rapid liver regeneration occurring in the early posttransplant period in recipients of living donor grafts may alter early virologic or immunologic events and thereby affect the risk of progressive liver disease. Also, live donor recipients are more likely than deceased donor recipients to share human leukocyte antigens and although the relationship between human leukocyte antigens matching and risk of recurrent HCV is controversial, it represents another difference between LDLT recipients and DDLT recipients that may affect HCV disease recurrence. Alternatively, because LDLT donors typically are younger and the ischemia times are shorter than with DDLT donors, outcomes may be better among recipients of LDLT than of DDLT. At the present time, these proposed mechanisms for an altered natural history of HCV infection in recipients of LDLT vs. DDLT remain speculative. The Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) is a consortium of 9 U.S. liver transplant centers performing adult-to-adult LDLT with the primary goal of examining outcomes of adult-to-adult LDLT vs. DDLT. Both retrospective and prospective studies are ongoing, aimed at garnering information on donor and recipient outcomes of LDLT over the decade from 1998 to 2008. In the present study, the retrospective A2ALL cohort was used to compare graft and patient survival and the risk of advanced fibrosis in HCV-infected recipients who underwent either LDLT or DDLT.