Patterns and Predictors of Mortality after Waitlist Dropout of Patients with Hepatocellular Carcinoma Awaiting Liver Transplantation

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 to 2016 in a single, large academic North-American center. Patients were divided into 3 groups according to the type(s) 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 and 3.3 months, respectively (P = .01). MELD score [HR = 1.04, 95%CI, 1.01-1.08)], alcoholic liver disease [HR = 1.66 (95%CI 1.02-2.71), and alpha 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 [0.32 95%CI 0.21-0.48)] for death. Conclusion: 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. * Andre Gorgen and Roizar Rosales contributed equally to this work. Conflicts of Interest: None to declare Financial support: None Address for correspondence: Dr. Gonzalo Sapisochin, Assistant Professor of Surgery, University of Toronto, Staff Surgeon, HBP & Multi Organ Transplant Program, Division of General Surgery. University Health Network, 585 University Avenue, 11PMB184, Toronto, M5G 2N2, ON, Canada,. T : +1 416 340 4800 ext. 5169 / F : +1 416 340 3237 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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