3802 Journal of Applied Sciences Research, 9(6): 3802-3808, 2013 ISSN 1819-544X This is a refereed journal and all articles are professionally screened and reviewed

ORIGINAL ARTICLES

Outcome of Living Donor Transplantation for : An Egyptian Experience

1Ayman Yousry, 1Mohamed Said, 2Wafaa M Ezzat, 2Amre M. Farag

1Endemic Diseases and Hepatogastroentrology Dept., Cairo University. 2Internal Medicine Dept., National Research Center.

ABSTRACT

The aim of our study was to examine the outcome results and recurrence rates for patients with HCC who underwent LDLT. This study was conducted on 25 adult recipients with Hepatocellular Carcinoma who underwent living donor at Dar El-Fouad hospital from August 2001 to January 2007 aiming to evaluate the outcome of living donor liver transplantation for HCC including survival rates, recurrence of HCC. Mean duration of follow up was 709±669 days; 14 patients (56%) were alive at the end of follow up, there was recurrence of liver fibrosis due to HCV infection in 6 cases (24%), Mean time of recurrence of hepatitis was 6.3±2.9 months; range was 1-9 months. While there was HCC recurrence in 2 cases (8%). Mean time of recurrence of HCC was 3.2±1.1 months; range was 3-4 months. The cause of death in HCC patients was: A) Biliary obstruction, leakage and sepsis in 7 cases. B) Massive bleeding (haematemesis, haemoptysis), congestion of liver graft, sepsis in 2 cases. C) Fresh bleeding per of unknown origin in 2 cases. There was no significant difference between cases inside and outside Milan criteria or between HCC and non-HCC patients as regard duration of survival. We concluded that living donor liver transplantation provides better prognosis and survival rates for patients with hepatocellular carcinoma. The main findings in outcome are histological recurrence of HCV and HCC. Main causes of death were biliary obstruction, leakage and sepsis.

Key words: hepatocellular carcinoma-living donor liver transplantation-outcome-survival.

Introduction

Hepatocellular carcinoma (HCC) is a major health problem, with more than 500.000 cases diagnosed annually (Jain , et al, 2010). The burden of hepatocellular carcinoma (HCC) has been increasing in Egypt with a doubling in the incidence rate in the past 10 years (Mizokami and Tanaka,2005). Estimates of the burden of cancer caused by avoidable factors like viral hepatitis provide an opportunity for prevention. Liver transplantation for treatment of HCC is attractive because resection of the malignant tumor can be achieved while also replacing the cirrhotic liver that remains at risk for the development of new lesions (Bruix et al, 2003). However, early experience with transplantation for patients with unresectable local HCC was disappointing. Living donor liver transplantation (LDLT) may represent a valid therapeutic option allowing several advantages for patients affected by hepatocellular carcinoma (HCC) (Yao et al, 2001). Ready availability is the most important advantage of LDLT for HCC. Posttransplant tumor recurrence is tied to pretransplant tumor stage; progression of tumor while awaiting transplant can only worsen the prognosis (Wiesner et al, 2004). Recognizing that patients with small, incidentally found tumors had survival rates after liver transplantation equivalent to those after transplantation for benign disease(Majno and Mazzaferro,2006), Mazzaferro and collegues, in Milan established criteria for OLT in a landmark study. They showed that a subgroup of patients with radiologic evidence of a single tumor ≤5 cm in diameter, or two to three tumors ≤3 cm in diameter had 5- year and recurrence-free survival rates of 75 and 83%, respectively (Mazzaferro et al,1996). Multiple studies which were addressing LT for HCC reported on various determinants of “high-risk pathology” for tumor recurrence and decreased patient survival. Milan criteria, and expanded set of criteria were proposed by the University of California San Francisco UCSF criteria which is referred to here as the “UCSF” criteria, allows patients with a solitary tumor smaller than 6.5 cm, or patients having 3 of fewer nodules, with the largest lesion being smaller than 4.5 cm or having a total tumor diameter less than 8.5 cm without vascular invasion, to undergo OLT. Tumor size, tumor number, lobar distribution, vascular invasion, tumor differentiation, and AFP levels were frequently found to predict patient outcomes post transplantation(Yao et al, 2006). Patients whose pathology lies outside of the formal criteria have an approximately 50% incidence of recurrence, suggesting that postoperative pathologic evaluation.

Corresponding Author: Wafaa M Ezzat, Internal Medicine Dept., National Research Center, Cairo, Egypt. E-mail: [email protected] 3803 J. Appl. Sci. Res., 9(6): 3802-3808, 2013

So that, the aim of our study was to examine the outcome results and recurrence rates for patients with HCC who underwent LDLT.

Patients and methods:

This is a retrospective study for 25 adult recipients who underwent living donor liver transplantation for HCC out of 129 recipients transplanted in Dar AL-Fouad Hospital in the period between August 2001 to January 2007.

Patients:

All studied recipients were males. Patients were evaluated preoperatively using the Child- Pugh (CPS) score, Model for End-Stage Liver Disease (MELD) Score and Milan criteria.

MELD Score Calculation:

MELD score=0.957xloge (creatinine mg/dL)+0. 378xloge (bilirubin mg/dl)+1.1 20xloge (INR)+0.643 (Cholongitas et al, 2006).

Inclusion criteria:

The enrolled patients in the current study who underwent living donor liver transplantation due to either well diagnosed or incidentally discovered HCC.14 patients were well diagnosed and 11 patients were incidentally discovered during operation. The other 104 patients underwent living donor liver transplantation due to liver of different etiologies but mainly chronic hepatitis C virus infection. Milan criteria were followed in selection of patients. The criteria for eligibility for transplantation were the presence of a tumor 5 cm or less in diameter in patients with single hepatocellular carcinoma and no more than three nodules, each 3cm or less in diameter, in patients with multiple tumors(Mazzaferro et al, 1996).19 patients were inside Milan criteria while 6 patients were outside.

Exclusion criteria:

A- Human immunodeficiency virus (HIV) seropositivity. B- Extra hepatic malignancy. C- Cholangiocarcinoma. D- Active uncontrolled sepsis. E- Advanced Cardiopulmonary disease.F- Active alcoholism or drug abuse. G- Anatomic abnormality precluding liver transplantation. H- Persistent renal dysfunction. All studied recipients were subjected to preoperative evaluation and postoperative follow up. The evaluation of the recipients prior to transplantation (according to Dar El Fouad Hospital protocol) was detailed and stepwise as follows: STEP I:Comprehensive history taking; Clinical examination.; Laboratory evaluation that includes: Blood Grouping , CBC and ESR; Liver Functions: Bilirubin (Total and direct),ALT ,AST ,Total Protein ,serum albumin ,Alkaline phosphatase, Gamma glutamyl transferase, Lactate dehydrogenase, Prothrombin time, concentration and INR; Renal Profile :Serum Creatinine , Urea ,Uric acid; Serum electrolytes: Sodium and potassium; Urine analysis, stool analysis and occult blood in stool; Serological tests: HCV Ab. HBsAg & HbcAb total; Fasting and postprandial blood sugar; Imaging: Abdominal and pelvic sonography and Vascular hepatic Doppler. STEP II: Bleeding time , clotting time , TT , Fibrinogen , ATIII, Protein C, Protein S& Factor V;C-reactive protein, VDRL, , Cholesterol, Triglycerides, Amylase, calcium, iron and TIBC ;Tumors markers: CA19.9 , CA125 , Alpha fetoprotein and CEA; Viral profile: HAV IgM / HAV total / HBs Ab / Hbc IgM / HBe Ab /Hbe Ag / HCV PCR (Qualitative and quantitative) / HIV I, HIV II / EBV IgM / EBV IgG / CMV IgM / CMV IgG/ Herpes I IgG / Herpes II IgG;Imaging & Other Procedures: Chest X-ray & Chest CT; Spiral Abdominal CT with contrast ;Doppler both LL (arteries & veins ) ;ECG;Echo cardiology ;Thalium scan;Renal scan ;Pulmonary function test and Upper GI endoscope .STEP III:Medical Evaluation: Cardiological consultation; Chest consultation;Nephrological consultation; ENT and dental consultation and Psychiatric consultation. The donors were evaluated in the same stepwise evaluation, their demographics and graft size (estimated, actual) in addition to estimated and actual Graft Recipient Weight Ratio (GRWR) were recorded to be evaluated as risk factors.

Post liver transplantation evaluation:

During the hospital stay, the patients were assessed daily by: Complete liver profile; Alpha-fetoprotein level; Kidney profile; Coagulation profile; CBC, Fasting blood sugar ;CRP; Immunosuppression drug level in the blood; Chest X-ray and Abdominal ultrasound and Hepatic Doppler.

3804 J. Appl. Sci. Res., 9(6): 3802-3808, 2013

Outpatients follow up:

The patients were assessed at outpatient basis weekly for first month then every 2 weeks for the second month then monthly for first year and every 3 months thereafter according to clinical situation by the same tests that were done during hospital stay.

Statistical analysis:

Statistical package for Social Science (SPSS, 12.0) was used in analysis. They were compared by t-student test. Repeated measures of these variables in follow up of the patients were compared by ANOVA and presented in line graphs by estimated marginal mean. They were compared using Chi-square test or Fischer's exact test when appropriate. In all tests, P value was significant at the level of 0.05.

Results:

All studied patients were males with mean age of 50±6.5; range was (37-62). HCV was the cause of CLD in 22 cases (88%), while both HCV and HBV were the cause of chronic liver disease (CLD) in only 3 cases (12%).classification of patients according to Child- Pugh score (CPS) showed that eleven cases (44%) were Child (B), fourteen cases (56%) were Child(C), Mean Meld score was 18±4, range was (11-30) as shown in table 1. Table(1) also shows the mean size of HCC lesions was 2.5±1.5, ranged from 0.5 to 6. The lesions were located in right lobe in 60% of cases, in left lobe in 20% of cases, in both lobes in 20% of cases as shown in table1. 19 cases were inside Milan criteria. There was portal vein invasion in 2 cases (8%), there was no micro vascular invasion, and all the lesions were well differentiated. Mean duration of follow up was 23.6±22.3 months; 14 patients (56%) were alive at the end of follow up, there was recurrence of liver fibrosis due to HCV infection in 6 cases (24%), Mean time of recurrence of hepatitis was 6.3±2.9 months; range was 1-9 months. While there was HCC recurrence in 2 cases (8%). Mean time of recurrence of HCC was 3.2±1.1 months; range was 3-4 months. The cause of death in HCC patients was: A) Biliary obstruction, leakage and sepsis in 7 cases. B) Massive bleeding (haematemesis, haemoptysis), congestion of liver graft, sepsis in 2 cases. C) Fresh bleeding per rectum of unknown origin in 2 cases as shown in table 2. There was no significant difference between cases inside and outside Milan criteria as regard duration of survival.

Table 1: Patient's characteristics and description of HCC lesions. Variables Age (years) Mean ± SD 50 ± 6.5 Etiology of CLD: HCV no(%) 22 (88) HCV+HBV no (%) 3 (12) Child Puph Score (CPS): B no (%) 11 (44) C no (%) 14 (56) MELD: <15 no (%) 5 (20) 15-20 no (%) 13 (52) 20-25 no (%) 6 (24) >25 no (%) 1 (4) HCC size (cm) of the largest (in explants) 2.5± 1.5 Mean ± SD HCC lesion Number 14 (56) Single No. (%) 11 (44) Multiple No. (%) Size of incidental lesions Mean ± SD 1.7+1 Incidental discovery of HCC No. (%) 11(44) Location: 15 (60) Rt lobe No. (%) 5 (20) Lt lobe No. (%) 5 (20) Both No. (%) Milan criteria Inside Milan No. (%) 19 (76) Outside Milan No. (%) 6 (24) Portal vein invasion No. (%) 2 (8) Micro vascular invasion No. (%) 0 (0) Well differentiated No. (%) 25 (100)

As regards impact of characteristics of HCC lesions on survival rate, it was found that the frequency of incidental lesions were significantly more frequent among dead patients as shown in table 3. 3805 J. Appl. Sci. Res., 9(6): 3802-3808, 2013

There was no significant difference between dead and alive patients as regards pre transplantation laboratory investigations including AFP as shown in table 4.

Table 2: Outcome of LDLT for studied patients with HCC. Variables P value HCC patients alive at the end of follow up No. (%) 14/25(56) Non-HCC patients alive at the end of follow up No. (%) 68/103(66) Hepatitis C recurrence No. (%) 6 (24) HCC recurrence No. (%) 2 (8) 1 year survival No. (%) 14(56) 3 years survival No. (%) 14(56) 5 years survival No. (%) 14(56) Cause of death of HCC patients: Biliary obstruction, leakage and sepsis No. (%) 7/11(63.6) Massive haematemesis, haemoptysis, sepsis, congestion of graft. No. (%) 2/11(18.2) Fresh bleeding per rectum of unknown origin. No. (%) 2/11(18.2) Duration of survival (in days) in relation to Milan criteria ,Mean ±SD Milan +ve (n= 19) 1332+246 Milan -ve (n= 6) 872+313.5 0.9(NS) Duration of follow up (in months ) 23.6±22.3 Time of recurrence of HCC (in months) 3.2±1.1 Time of recurrence of HCV (in months) 6.3±2.9

Table 3: Relationship between age; clinical stage; characteristics of HCC lesions and patients' outcome. Variables Alive (n=14) Dead (n=11) P Value Age(years) Mean ± SD 48.5± 7.5 52± 5.5 0.230 (NS) MELD score, Mean ± SD 18.2 ± 3.7 18.2 ± 5.3 0.986 (NS) CPS Mean ± SD 9.6 ± 1.4 9.3.3± 0.6 (NS) HCC size(the largest in cm) Mean ±SD 2.5 ±0.9 2.5 ± 1.8 0.8 (NS) HCC lesion Number Single no (%) 8 (57.1) 6 (54.5) 0.8 (NS) Multiple no (%) 6 (42.9) 5 (45.5) Incidental lesions 3 (21.4%) 8 (72.7%) 0.02(S) Location: Right lobe no (%) 11 (78.6) 4 (36.4) Left lobe no (%) 2 (14.3) 39 (27.3) 0.08(NS) Both no (%) 1 (7.1) 4 (36.4) Milan Criteria: Inside Milan no (%) 11 (78.6) 8 (72.7) 1.00(NS) Outside Milan no (%) 3 (21.4) 3 (27.3)

Table 4: Relationship between Pre-operative laboratory data and outcome of studied recipients. Variables Alive Dead Mean ±SD Mean ±SD P value T. Bilirubin 3.8±1.9 6.44±11.03 0.387 (NS) D. Bilirubin 1.4±1 3.1±6.4 0.359 (NS) AST 71.3±53.7 100.6±42.4 0.152 (NS) ALT 46.2±31.7 59.3±28.7 0.298 (NS) AKP 105.4±55.9 94.4±35. 0.577 (NS) GGT 61.9±49.5 53.4±48 0.668 (NS) ALBUMIN 2.6±0.5 2.65±0.3 0.581 (NS) P.C 43.8±8.7 46.1±8.1 0.508 (NS) INR 1.9±.3 1.8±.2 0.594 (NS) Hb 11.8±2.1 11.2±1.5 0.459 (NS) PLT 89428.6±74457.7 56636.4±15869.9 0.131 (NS) AFP 221.7±512.8 66.1±118.473 0.851(NS) P value <0.05 = Significant NS: Non Significant

Discussion:

In Egypt and in Arab countries data about the outcome of liver transplantation for HCC patients are scarce. Our study is aiming to evaluate the outcome of living donor liver transplantation for HCC including survival rates, recurrence and risk factors. In the current study, it was found that the overall 1,3,and 5 years survival rates were 56% while Sandro and his colleagues proved that The overall 3- and 5-year survival rates were 77.3% and 68.7% for LDLT recipients, respectively(Di Sandro et al, 2009).the difference between our results and this study was that the studied patients are different in ethnicity and different underlying causes for chronic liver disease as viral hepatitis and economic causes may contribute that cause longer duration for waiting to undergo LDLT. 3806 J. Appl. Sci. Res., 9(6): 3802-3808, 2013

In our study HCC recurred in only 2 cases (8%) after liver transplantation and the mean time of recurrence of HCC were 3.2±1.1 months after transplantation. This is in agreement with Rayya and his collegues., (Rayya et al, 2008) who recorded HCC recurrence rate of 9% while Martin and his collegues, recorded a lower HCC recurrence rate (4%). This is reflected to what extent the Milan's criteria are successful as an allocation system for HCC patients for liver transplantation (Martin et al, 2008). Vivarelli and Risaliti said that Although in absolute terms the results of liver transplantation for HCC are outstanding, considering that we are dealing with a highly aggressive tumor, 10% to 20% of recipients still develop tumor recurrence. This failure rate is of particular relevance in the transplantation field where great effort is made not to waste precious and rare resources such as liver grafts (Vivarelli and Risaliti, 2011). To quantify the extent of the possible gain in terms of recurrence-free survival Vivarelli and Risaliti concluded that the careful selection of candidates based on macroscopic tumor findings is a cornerstone that seems to have been exploited to the maximum. Thus, better characterization of tumor biology is necessary; the main problem in this field is outlining markers assessable on tumor biopsy. It has been postulated that the rapidity of liver regeneration (Vivarelli and Risaliti, 2011). Can have a stimulatory effect on residual tumor cells, leading to higher HCC recurrence associated with partial transplants. A recent animal model supports this hypothesis(Bartlett and Heaton, 2008). Histologic recurrence of HCV after LT is universal and is considered one of the causes of death in recipients with HCC after liver transplantation (Shi et al ,2011). In our study HCV recurred in 6 cases (24%) and the mean recurrence time of HCV was 6.3±2.9 months after transplantation, which is to some extent in agreement with Martin and his collegues (Martin et al, 2008)who recorded HCV recurrence rate of 30%of the cases with HCC and HCV undergoing liver transplantation. Our study is also in agreement with a recent study conducted In Dar El-Foad Hospital in which HCV recurrence was observed in 10/38 patients (26.3%). (Yosry et al, 2008). Everson and Trotter discuss increased genetic donor- recipient similarity as a potential cause for more severe HCV recurrence. Hepatic regeneration leading to increased viral uptake by hepatocytes through stimulation of low-density lipoprotein receptor expression and activity might play a decisive role in more rapid and extensive HCV reinfection(.Everson and Trotter, 2003). In our study there was a significant difference between alive and dead patients as regard HCV recurrence. There was no mortality in any of the cases in which HCV recurrence occurred, because of all of our series mortalities occurred during one year post transplantation and no was done for these cases. Patients with incidental or occult HCC, discovered in the explanted liver, usually have a better prognosis since these nodules are usually small. However in our study HCC was incidentally discovered in 11 cases (44%) and the mortality significantly increased in cases with incidental lesions, whereas another study showed that while incidental HCC was found to be associated with decreased survivals, it was not an independent predictor of poor recipient outcomes (Becker et al, 2008). Briceño and his colleagues found that Five-year survival after liver transplantation was about 20% better for incidental tumors. However, incidental tumors showed similar rates of HCC recurrence after transplantation (Briceño et al, 2008). These results contrasted with those reported by Shetty and colleagues for incidental tumors with a smaller size and favorable stage, but with similar survival/ recurrence rates compared to nonincidental tumors (Shetty et al, 2011). Data from both UCSF and the University of Pittsburgh (Iwatsuki et al, 2000) show similar results. Recently, data from the International Tumor Registry (Molmenti and Klintmalm, 2002) reported better overall survival among the incidental cohort than the group with known HCC, but with a 15% recurrence rate for incidental tumors. In our study, incidental tumors were not predictive of survival/ recurrence, irrespective of pTNM classification and/or vascular invasion. The different prognosis of incidental versus nonincidental groups may be explained by the high percentage of advanced pTNM stage and vascular invasion among patients with nonincidental HCC. Patients with incidental tumors do as poorly as those who have known tumors and who receive transplants.( Klintmalm, 1998). Several risk factors may impact outcome of transplantation for HCC patients, operative difficulties in our study was a significant predictor of mortality, while age of recipients had no impact on their survival after transplantation, and this in contrast to Patel and his colleagues who stated that age of recipients was a significant predictor of survival. This contradiction may be reflected to small size of patients sample included in the current study, different circumstances around living donor liver transplantation in Egypt like shortage of donors and financial support (Patel et al, 2007). It is well accepted that higher Child class is an independent poor prognostic factor in liver transplantation (Seaberg et al, 1999), and MELD score has replaced CHILD score as better predictor of outcome, in our study there was no significant relation between Child score or MELD score and post-transplantation survival. This is in contrast with previous studies who reported that HCC patients with Meld score greater than 20 had poor post- transplantation survival(Ioannou , 2006), also, Patel and his colleagues reported that Meld score greater than 25 was a significant predictor of survival after transplantation (Patel et al, 2007). We think that the difference 3807 J. Appl. Sci. Res., 9(6): 3802-3808, 2013 between results of the current study and results of previous studies may be referred to contribution of other factors like surgical difficulties, co morbid underlying factors of chronic liver diseases in Egypt like hepatic schistosomiasis. Milan criteria did not offer better results in our study as regard patients or graft survival, the only impact was on the low rate of recurrence. And this is in agreement with a study that showed that Patients meeting Milan criteria had similar post-transplant survival to patients not included in Milan criteria(Duffy et al, 2007), whereas another study showed that The survival was arithmetically lower in patients outside Milan compared to patients inside Milan but this difference was not significant (Decaens et al, 2006). In our study all patients received adequate graft size with appropriate GRWR, none of our series suffered from small for size syndrome, so we did not find any impact for the graft size and GRWR on outcome of transplantation. After all, it was evident that living donor liver transplantation is an effective therapeutic modality which can improve prognosis and survival of HCC patients. LDLT can create brighter future for these patients. The usual outcome is poor, because only 10 – 20% of hepatocellular carcinomas can be removed completely using surgery. If the cancer cannot be completely removed, the disease is usually deadly within 3 to 6 months (Roberts, 2011). Conclusion living donor liver transplantation provides better prognosis and survival rates for patients with hepatocellular carcinoma. The main findings in outcome are histological recurrence of HCV and HCC. Main causes of death were biliary obstruction, leakage and sepsis.

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