*Purpose: Hepatocellular carcinoma (HCC) has become a leading indication for liver transplantation (LT) globally. Given the scarcity of organs, the general consensus has been that liver transplantation should be reserved for HCC patients who have a predicted 5-year survival similar to non-HCC patients. In the new era of transplant oncology, we sought to perform a multi-national comparison of donor and recipient characteristics, trends in LTs performed for HCC, and post-LT long-term survival.

*Methods: We studied consecutive adults (≥18-years) who underwent first-time LT for HCC between Jan-2008 and Dec-2018 from three national liver transplantation registries (United Network for Organ Sharing STAR [United States (US)], National Health Service Blood and Transplant [United Kingdom (UK)], and Canadian Organ Replacement Registry [Canada]).

*Results: A total of 22,404 LTs performed for HCC were identified (US n=19,776, Canada n=1,005, UK n=1,623). The UK had the shortest waitlist time but longest cold ischemia times, highest donor ages, and the highest proportion of deceased after circulatory death donor use. Canada had the highest proportion of living donor liver transplant donor use. 5- and 10-year post-transplant survival exceeded 72% and 58% in all countries. Relative to the US, the overall adjusted mortality hazard was equivalent for Canada but lower in the UK (Canada:HR 0.90, 95% CI 0.76-1.07; UK:HR 0.87, 95% CI 0.77-0.99).

*Conclusions: This represents the largest and only population-based multi-national analysis of LT for HCC. Identifying differences in recipient, donor, and transplant characteristics between countries offers opportunities for benchmarking, optimization of transplant practices, and ultimately improved post-transplant outcomes.

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