Liver Transplantation in Patients with and Without Hepatocellular Carcinoma Between 1997 and 2016 in the United Kingdom: An Analysis of Changes in Short and Long-Term Post-Transplant Mortality

Background: The rising incidence of hepatocellular cancer (HCC) is increasing the demand for liver transplantation. Consequently, there have been significant changes in characteristics of donors and recipients. We evaluated short-term and long-term mortality of HCC and non-HCC recipients in successive 5-year time-periods ('eras') between 1997 and 2016. Methods: First-time single-organ elective adult liver transplant recipients were identified in a national dataset of all liver transplantations in the UK. We estimated hazard ratios (aHR) adjusted for recipient characteristics to compare mortality by era. We estimated the impact of era separately on short-term (first 90 days) and on longer-term mortality (from 90 days to 5 years). Findings: 1 879 HCC recipients and 7 661 non-HCC recipients were included. The proportion of HCC recipients increased from 13.0% (275/2117) in era 1 (1997-2001) to 23.9% (727/3042) in era 4 (2012-2016). There was an increase in use of donors following circulatory death from 0% in era 1 to 35.2% in era 4 for HCC recipients and from 0.2% to 24.1% for non-HCC recipients. 3-year mortality decreased from 28.3% in era 1 to 16.9% in era 4 (aHR: 0.47, 95%CI: 0.35-0.63) for HCC recipients and from 20.4% to 9.3% (aHR: 0.44, 0.36-0.53) for non-HCC recipients. Comparing era 1 and era 4, improvements in short-term mortality were significantly more marked than in long-term mortality both for HCC (aHR 0-90 days: 0.20, 0.10-0.39; 90 days-5 years: 0.52, 0.35-0.75; p=0.04) and for non-HCC recipients (aHR 0-90 days: 0.32, 0.24-0.42; 90 days-5 years: 0.52, 0.40-0.67; p=0.02). Interpretation: In last 20 years, mortality after liver transplantation in the UK has more than halved for HCC and non-HCC recipients, despite an increasing use of sub-optimal donor organs. Improvements in overall survival in both HCC and non-HCC recipients can be explained by decreases in short-term and in longer-term mortality. Funding Statement: National Institute of Health Research. DW is funded by a Doctoral Research Fellowship from the National Institute of Health Research. JvdM is partly supported by the NHS National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care North Thames at Bart’s Health NHS Trust. Declaration of Interests: JvdM reports grants from Healthcare Quality Improvement Partnership during the conduct of the study. All other authors declare no competing interests. Ethics Approval Statement: The study received ethics and governance approvals from the following organisations: NHS Health Research Authority’s London - Brighton & Sussex Research Ethics Committee (17/LO/0231) and NHS Health Research Authority’s Confidentiality Advisory Group (17/CAG/0025).