Donation after Circulatory Death is Associated with Similar Post‐Transplant Survival in All but the Highest Risk Hepatocellular Carcinoma Patients

Liver transplantation (LT) recipients with hepatocellular carcinoma (HCC) receive a higher proportion of livers from donation after circulatory death (DCD) donors compared to non-HCC etiologies. Nevertheless, data on outcomes in patients with HCC receiving DCD grafts are limited. We aimed to evaluate the influence of DCD livers on post- LT outcome among HCC patients. We identified 7,563 patients in the UNOS database who underwent LT with MELD exception from 2012-2016, including 567 (7.5%) who received a DCD donor and 6996 (92.5%) who received a donation after brain death (DBD) donor. Kaplan-Meier probabilities of post-LT HCC recurrence at 3 years were 7.6% for DCD and 6.4% for DBD (p=0.67) and post-LT survival at 3-years was 81% vs 85%, respectively (p=0.008). On multivariable analysis, DCD (HR 1.38, p=0.005) was an independent predictor of post-LT mortality. However, a survival difference post-LT was only observed in subgroups at higher risk for HCC recurrence including RETREAT score ≥4 (DCD 57% versus DBD 73%, p=0.02), AFP ≥100 (60% versus 77%, p=0.049), and multiple viable tumors on last imaging before LT (70% versus 83%, p=0.002). CONCLUSION: In this analysis of HCC patients receiving DCD versus DBD livers in the UNOS database, we found that patients with a low to moderate risk of HCC recurrence (80-90% of the DCD cohort) had equivalent survival regardless of donor type. It appears that DCD donation can best be utilized to increase the donor pool for HCC patients with decompensated cirrhosis or partial response/stable disease after local-regional therapy with AFP at LT <100 ng/ml.