Serum alpha-fetoprotein level independently predicts posttransplant survival in patients with hepatocellular carcinoma

Authors

  • Kristin Berry,

    1. Research and Development and Veterans Affairs Puget Sound Health Care System, Seattle, WA
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  • George N. Ioannou

    Corresponding author
    1. Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System, Seattle, WA
    2. University of Washington, Seattle, WA
    • Research and Development and Veterans Affairs Puget Sound Health Care System, Seattle, WA
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  • Kristin Berry contributed to the study concept and design, the acquisition of data, the analysis and interpretation of data, a critical revision of the manuscript, and the statistical analysis. George N. Ioannou contributed to the study concept and design, the acquisition of data, the analysis and interpretation of data, the drafting of the manuscript, a critical revision of the manuscript, and the statistical analysis.

  • This study was supported by the Research Enhancement Award Program of the Veterans Affairs Office of Research and Development.

  • This research is based on data derived from the United Network for Organ Sharing in October 2011. This work was supported in part by Health Resources and Services Administration contract 231-00-0115. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services.

Address reprint requests to George N. Ioannou, B.M.B.Ch., M.S., Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, S-111-Gastro, Seattle, WA 98108. Telephone: 206-277-3136; FAX: 206-764-2232; E-mail: georgei@medicine.washington.edu

Abstract

We aimed to determine whether combining serum alpha-fetoprotein (AFP) level with hepatocellular carcinoma (HCC) tumor burden would allow better stratification of posttransplant survival for patients with HCC undergoing liver transplantation. Adjusting for donor and recipient characteristics, we calculated the risk of posttransplant mortality associated with serum AFP level or HCC tumor burden for all first-time adult liver transplants performed in the United States between 2002 and 2011 (n = 45,267). Serum AFP level, rather than tumor burden, was the tumor characteristic most strongly associated with posttransplant survival. Although recipients with HCC and a serum AFP level ≤ 15 ng/mL at the time of transplantation had no excess posttransplant mortality [adjusted hazard ratio (AHR) = 1.02, 95% confidence interval (CI) = 0.93-1.12], patients with a serum AFP level of 16 to 65 ng/mL (AHR = 1.38, 95% CI = 1.23-1.54), patients with a serum AFP level of 66 to 320 ng/mL (AHR = 1.65, 95% CI = 1.45-1.88), and patients with a serum AFP level > 320 ng/mL (AHR = 2.37, 95% CI = 2.06-2.73) had progressively worse posttransplant mortality in comparison with recipients without HCC. Patients with a tumor burden exceeding the Milan criteria (who are usually excluded from transplantation) had excellent posttransplant survival if their serum AFP level was 0 to 15 ng/mL (AHR = 0.97, 95% CI = 0.66-1.43). In contrast, patients within the Milan criteria (who are routinely considered to be transplant candidates) had poor survival if their serum AFP level was substantially elevated (for a serum AFP level ≥ 66 ng/mL, AHR = 1.93, 95% CI = 1.74-2.15). Changes in serum AFP level while patients were on the waiting list corresponded closely to changes in posttransplant mortality. In conclusion, the absolute serum AFP level and changes in the serum AFP level strongly predict posttransplant survival independently of the tumor burden. We hope that these data, in combination with other factors, can be used to inform future studies and ongoing discussions aimed at improving the eligibility criteria for liver transplantation for patients with HCC. Liver Transpl 19:634–645, 2013. © 2013 AASLD.

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