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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

26 Pages Posted: 2 Aug 2019

See all articles by David Wallace

David Wallace

London School of Hygiene and Tropical Medicine - Department of Health Services Research and Policy; NHS Foundation Trust - Institute of Liver Studies

Thomas E. Cowling

London School of Hygiene and Tropical Medicine - Department of Health Services Research and Policy

Kate Walker

London School of Hygiene and Tropical Medicine - Department of Health Services Research and Policy

Abid Suddle

NHS Foundation Trust - Institute of Liver Studies

Ian Rowe

University of Leeds - Leeds Institute for Data Analytics

Chris Callaghan

Guy's Hospital

William Bernal

NHS Foundation Trust - Institute of Liver Studies

Nigel Heaton

NHS Foundation Trust - Institute of Liver Studies

Jan van der Meulen

London School of Hygiene and Tropical Medicine - Department of Health Services Research and Policy

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Abstract

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).

Suggested Citation

Wallace, David and Cowling, Thomas E. and Walker, Kate and Suddle, Abid and Rowe, Ian and Callaghan, Chris and Bernal, William and Heaton, Nigel and Meulen, Jan van der, 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 (March 5, 2019). Available at SSRN: https://ssrn.com/abstract=3384892 or http://dx.doi.org/10.2139/ssrn.3384892

David Wallace (Contact Author)

London School of Hygiene and Tropical Medicine - Department of Health Services Research and Policy ( email )

London
United Kingdom

NHS Foundation Trust - Institute of Liver Studies ( email )

London
United Kingdom

Thomas E. Cowling

London School of Hygiene and Tropical Medicine - Department of Health Services Research and Policy

London
United Kingdom

Kate Walker

London School of Hygiene and Tropical Medicine - Department of Health Services Research and Policy

London
United Kingdom

Abid Suddle

NHS Foundation Trust - Institute of Liver Studies

London
United Kingdom

Ian Rowe

University of Leeds - Leeds Institute for Data Analytics

Leeds, LS2 9JT
United Kingdom

Chris Callaghan

Guy's Hospital

Great Maze Pond
London SE1 9RT
United Kingdom

William Bernal

NHS Foundation Trust - Institute of Liver Studies

London
United Kingdom

Nigel Heaton

NHS Foundation Trust - Institute of Liver Studies

London
United Kingdom

Jan van der Meulen

London School of Hygiene and Tropical Medicine - Department of Health Services Research and Policy

London
United Kingdom

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