Survival Benefits Of Living Donor Liver Transplant For Hepatorenal Syndrome Candidates On Waitlist

Introduction: The utilization of living donor liver transplant (LDLT) for candidates with hepatorenal syndrome (HRS) is controversial. Method: This was a retrospective study from the University of Hong Kong. All data was retrieved from a prospective collected database. All liver transplant candidates who were accepted on waitlist from 2008 to 2017 were analyzed. Patients were divided into 2 groups. For candidates who had at least one potential live donor, they would be considered as “intention-to-treat LDLT group” (ITT-LDLT). Whereas patients who had no live donor would belong to “intention-to-treat DDLT group” (ITT-DDLT). HRS was defined as acute kidney injury (AKI) in patients with cirrhosis after ruling out other causes of AKI. All patients were treated with intravenous albumin and terlipressin, +/- renal replacement therapy. Primary outcome was to compare the ITT-overall survival for ITT-LDLT vs. ITT-DDLT for candidates with HRS. Results: 992 patients were listed (496 in ITT-LDLT and 496 in ITT-DDLT). 352(36.6%) patients had HRS. Baseline characteristics of all patients were listed in table 1. Patients in ITT-LDLT HRS. There were more female in ITT-LDLT group and they were sicker (higher MELD and more ICU candidates). The overall survival of ITT-LDLT was better than ITT-DDLT in HRS candidates. (Figure 1). The 1-, 3-, and 5-year survival was 66.5%, 59.5%, and 58.7% in ITT-LDLT HRS and they were 54.6%, 41.4%, and 39.4% in ITT-DDLT HRS (p<0.001).191 patients (DDLT n=116, LDLT n=75) underwent liver transplant. There was no difference in perioperative outcomes including mortality and morbidity between the 2 groups. Post-transplant survival at 1-, 3-, and 5-year were also similar. Conclusion: This was the 1st study to show that with ITT analysis, ITT-LDLT offered significant survival benefits than ITT-DDLT in HRS patients. Waitlist dropout/mortality should be considered and ITT-LDLT allowed a timely access to transplant. Similar perioperative and post-transplant outcomes suggested LDLT was justified in HRS patients.