Introduction: Cholangiocarcinoma (CCA) is the second most common primary neoplasm of the liver after hepatocellular carcinoma (HCC) and is associated with a high rate of mortality. Living donor liver transplantation (LDLT) with neoadjuvant chemoradiation has been utilized for the management of unresectable CCA in highly selected patients, though data on post LDLT survival are limited. We aimed to evaluate survival in patients with CCA post-LDLT in comparison to HCC.

Methods: We conducted an analysis using the United Network for Organ Sharing (UNOS)/OPTN database, evaluating patients with diagnostic codes for CCA who received LDLT from January 2010 to December 2022. We used HCC and non-HCC-CCA patients for comparison. Our primary outcome was post-transplant survival. Kaplan Meier curves were used for survival analysis. A stepwise multivariate analysis, adjusting for recipient age, gender, race, underlying etiology was performed.

Results: A total of 102(2.6%) LDLT recipients with CCA, 774 patients with HCC(19.4%), and 3117 (78.0%) without HCC or CCA were identified. Patients with CCA were younger compared to HCC group (51.1 vs. 59.2, p<0.001). Majority of patients with CCA were white (96.1%) compared to 71.5% in the HCC group (p<0.001). The most common etiology of liver disease in HCC was HCV 45.7%, followed by MAFLD 20.4%, ALD at 9.6%. Only 3.2% of HCC patients had a diagnosis of PSC. In CCA group 38.2% had PSC, while 61.8% were non-PSC patient. The most common regions for LDLT for CCA were region 7 (54.9%) and 2 (12.7%), while most common regions for HCC were region 2 (20.9%), 5 (18.0%), and 9 (15.9%). 1, 3, and 5-year post-LT survival for patients with CCA was 84.6%, 70.4%, 62.2% compared to HCC at 93.1%, 85.2%, 78.2%, respectively (p = 0.001). On multivariate analysis, HCC and CCA recipients had a higher hazard of mortality compared to non-HCC/CCA LDLT recipients (HR=1.345, 95% CI 1.113-1.625, and HR=2.974, 95% CI 2.120-4.172, respectively).

Discussion: LDLT for management of unresectable CCA is available in certain regions of the country with expertise under strict protocols. Patients with CCA have significantly lower survival compared to patients with HCC after LDLT with 5-year post LDLT survival of 62.2%. Outcomes of LDLT in CCA are dependent on careful pre-transplant selection due to concern for high rate of post liver transplant recurrence and death. Center-specific outcomes on post-LDLT survival should be explored to establish unified and effective selection protocols in CCA.

Post LDLT survival in recipients with CCA, compared to HCC, and non-HCC-CCA

Ahmet Gurakar

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