N. Charland1, K. Maeda2, C. Thornley2, M. Ha1, S.S. Ebaid1,2, V.G. Agopian1,2, D.G. Farmer1,2, F.M. Kaldas1,2 1David Geffen School Of Medicine, University Of California At Los Angeles, Los Angeles, CA, USA 2University Of California – Los Angeles, Department Of Surgery, Division Of Liver And Pancreatic Transplantation, Los Angeles, CA, USA
Introduction:
Liver transplantation (LT) can be an effective and durable treatment for cholangiocarcinoma (CCA). Multiple studies have indicated the superiority of LT over resection or systemic therapy alone in the treatment of locally advanced CCA, particularly among patients undergoing neoadjuvant chemotherapy. However, critical organ shortages remain, and the role of living donor liver transplantation (LDLT) for CCA is under active investigation. To date, no national study has compared patient and graft survival between LDLT and deceased donor liver transplantation (DDLT) among an exclusive CCA cohort.
Methods:
We present a retrospective analysis of all single-organ, adult liver transplant recipients in the United Network for Organ Sharing (UNOS) database from June 1988 to March 2024. Patients listed with a primary or secondary diagnosis of cholangiocarcinoma at the time of transplant were extracted and divided into DDLT and LDLT cohorts, as appropriate. Kaplan-Meier analysis was used to compare graft and patient survival at 1, 5, and 10 years. Multivariate regression models were used to investigate the relationship between donor type and postoperative complications.
Results:
Of 364,895 adult patients listed for liver transplantation from 1988 to 2024, 1,339 patients (0.4%) were listed with a primary or secondary indication of CCA. 806 (60.2%) of these patients were ultimately transplanted, with 676 (83.9%) receiving DDLT and 130 (16.1%) undergoing LDLT. Over the study period, the use of LDLT for CCA increased from 1 patient in 1988 to 36 patients in 2023, with a high of 58 patients in the years 2019 and 2020. This growth did not achieve statistical significance upon nonparametric testing (nptrend=0.48). LDLT recipients and their donors demonstrated a younger median age (51 vs 55 years, p=0.015; 38 vs 46 years, p< 0.001) than their DDLT counterparts. Additionally, the LDLT cohort demonstrated a lower median waitlist time (101 vs 136 days, p=0.04) and model for end-stage liver disease (MELD) score at transplant (9 vs 11, p=0.001). The proportion of patients receiving neoadjuvant chemotherapy was similar (63.0 vs 69.0%, p=0.54). After exclusion of patients lost to follow-up, LDLT demonstrated comparable short and long-term patient survival compared to DDLT (1-year, 89.6 vs 88.7%, p=0.81; 5-year, 62.7 vs 61.6%, p=0.20; 10-year, 54.5 vs 46.4%, p=0.39). Graft survival at all time points (1, 5, and 10 years) was similar between cohorts. Notably, LDLT for CCA was associated with significantly greater odds of postoperative hepatic artery thrombosis compared to DDLT (OR 7.1, p=0.01).
Conclusion:
LDLT is an effective alternative to DDLT for patients with a primary diagnosis of cholangiocarcinoma, with absolute 10-year patient survival exceeding that of DDLT. Caution should be employed in the use of LDLT for CCA patients at high risk of vascular complications. More investigation is needed to determine whether older CCA liver recipients may benefit from LDLT donors and reduced waitlist times.