Living donor liver transplantation for early hepatocellular carcinoma: A life-expectancy and cost-effectiveness perspective

Cadaveric liver transplantation (CLT) is an excellent treatment for early h epatocellular carcinoma (HCC). Its use, however, is limited by the shortage of grafts, with up to 30% of patients developing contraindications to the procedure while waiting for a donor. Living donor liver transplantation (LD LT) has emerged as an alternative to overcome this limitation. We compared the consequences of LDLT versus CLT using a Markov model balancing the gain s and losses in life expectancy among donors and recipients. For a 60-year- old recipient with a 70% 5-year survival after transplantation, a 4% monthl y drop-out rate, and a donor with 1% mortality, LDLT became more effective than CLT after 3.5 months on the waiting list, These results varied with th e probability of developing contraindications to transplantation, the survi val after transplantation, and the donor's mortality. For a 12-month delay saved on the waiting list, the gain in survival provided by LDLT compared w ith CLT ranged between 0 and 2.8 life years depending on survival after tra nsplantation, time spent on the waiting list, and drop-out rate. LDLT was c ost-effective (less than $50,000 per quality-adjusted life year saved) in a ll scenarios of waiting lists exceeding 7 months, and this figure ranged fr om 2 to 16 months when varying the drop-out rate. LDLT for early HCC offere d substantial gains in life expectancy with acceptable cost-effectiveness r atios when the waiting list exceeds 7 months. The gain in life expectancy a nd the cost-effectiveness of LDLT were more dependent on the drop-out rate and the outcome after transplantation than on donor's mortality.