Liver Transplantation in Patient With Acute Renal Failure?
The patient is a 63-year-old woman with cirrhosis secondary to hepatitis B virus (HBV) and hepatocellular carcinoma (HCC). She has multiple (7-10) HCC lesions; the largest lesion is 4 cm. She has portal vein thrombosis, presumably secondary to a distal spleno-renal shunt performed 20 years ago, stable for 2 years. An MRI shows no extrahepatic invasion. She was scheduled for living-donor liver transplantation and 3 days prior to this she developed acute renal failure. Her performance score is low. Do you consider her a candidate for liver transplantation?

Because there is a severe shortage of cadaveric livers, not all patients who may benefit from liver transplantation for HCC will have the opportunity to receive one. Therefore, transplantation listing criteria must balance the need for transplantation with the success after transplantation. The current accepted criteria for liver transplantation for HCC are the Milan criteria. These criteria have been adopted by the United Network for Organ Sharing as the criteria for allocation of cadaveric organs and include: solitary tumor < 5 cm, or 3 or fewer lesions (none > 3 cm), without gross vascular invasion. The results from this study revealed that the survival rate for liver transplantation in patients with small HCC is equivalent to that of patients without HCC.

However, some have argued that these criteria may be too restrictive. The University of California at San Francisco group have used the following criteria: solitary tumor ≤ 6.5 cm, or 3 or fewer nodules with the largest lesion ≤ 4.5 cm and total tumor diameter ≤ 8 cm, without gross vascular invasion. Transplantation using these criteria appears to have survival outcomes similar to outcomes obtained using the Milan criteria. The University of Pittsburgh group uses a modified TNM staging, and has proposed more individualized risk assessment using tumor biologic and genetic markers, potentially providing transplantation to more patients at lower risk for recurrence.

The application of living donor liver transplantation (LDLT), not subject to allocation criteria, poses a unique ethical dilemma: What level of futility is considered unacceptable not only for the resource outlay for liver transplantation, but also for the potential life-threatening risk to the donor? Nevertheless, at certain centers, parameters outside of the Milan criteria have been used for LDLT. In Japan, where cadaveric liver donation is scarce, reliance on LDLT is critical. The Kyoto group has reported preliminary data on their experience of LDLT for patients with HCC tumors in excess of the Milan criteria. With median follow-up of less than 1 year, 25% of the LDLT recipients experienced recurrence; this figure will assuredly increase with further follow-up. Last, the use of LDLT in cases of advanced liver failure is also controversial. It has been shown in early adult-to-pediatric LDLT that outcomes in critically ill children are poorer. In a recent subset analysis of 7 patients with a MELD score > 30, 4 patients subsequently died. Furthermore, in this group, 46% of donors experienced a complication.

In conclusion, the case presented is one in which conventional wisdom would suggest that the patient is not a candidate for transplantation. The technical challenge aside (portal vein thrombosis is considered by some to be a relative contraindication), the biologic nature of the HCC is high risk, as is graft loss and death in a patient with renal failure. More than likely, the chances of survival at 1 year would be significantly lower than 50% (more likely around 20% to 30%). However, some have argued that it would be the donor and recipient's prerogative to make the decision about whether to proceed.