The “Model of Recurrence after Liver Transplant” (MORAL) study has identified certain pre and post operative variables that have significant impact on recurrence free survival (RFS) post liver transplantation in patients with hepatocellular carcinoma (HCC). However, less than 10% patients underwent a living donor liver transplant(LDLT)in this study. It remains controversial whether LDLT is associated with increased risk of recurrence versus DDLT. Here, we have attempted to validate the MORAL score exclusively in a cohort of patients who underwent LDLT. We retrospectively reviewed patients who underwent LDLT for HCC between April 2012 and June 2017 and had HCC on explant histopathology (n=117). Demographics, patient and tumor characteristics and recurrence rate was assessed. The Pre and Post MORAL variables were used to determine difference in RFS post transplantation. Median follow up was 20.3(1-63.2)months. Out of total 117 patients, 90(76.9%) fulfilled Milan criteria, 7 (5.9%) fulfilled UCSF criteria and 20(17.2%) fulfilled Hangzhou criteria. Median tumor size was 2.5 (0.5-11) cm. More than one tumor nodule was present in 58/117 (49.6%) patients. Overall recurrence rate was 12/117 (10.3%). The actuarial 4 year RFS in patients with 0, 1 or 2 Pre Moral variables was 87%, 87% and 71% (P=0.5). The actuarial 4 year RFS in patients with 0, 1 or 2 Post MORAL variables was 90%, 88% and 77% (P=0.2). Out of Pre Moral variables, increasing an AFP cut off to 600 ng/ml had significant impact on RFS (88% versus 52%)(P=0.003). Out of Post Moral variables, presence of vascular invasion (VI) was associated with significantly worse RFS (92% versus 70%)(P=0.004). Combining these two prognostic variables, the RFS reduced to 38% ( VI+/AFP+) from 93% (VI-/AFP-)(P <0.001). On multivariate analysis, AFP >600 ng/ml[HR=3.9, P=0.02] and VI[HR=4.3, P=0.03] were associated with a four fold increase in risk of recurrence. In a pure LDLT setting, out of all MORAL variables, AFP > 600 ng/ml and vascular invasion remain exclusive predictors of post transplant recurrence.

CITATION INFORMATION: Bhatti A., Qureshi A., Khan N., Butt M., Waheed A., Rana A., Dar F. Validating MORAL in Living Donor Liver Transplantation for Hepatocellular Carcinoma Am J Transplant. 2017;17 (suppl 3).

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