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Page 10 of 15 Molinari et al. Hepatoma Res 2018;4:56 I http://dx.doi.org/10.20517/2394-5079.2018.71

Overall survival of the entire cohort of patients after liver transplantation for hepatocellular carcinoma

Cum survival

Time after liver transplantation (years)

Time after liver transplantation (years)
0 1 2 3 4 5
N. patients at risk 6048 4671 3500 2691 1983 1398

Figure 2. Kaplan Meier survival function representing the 5-year overall survival of all patients undergoing liver transplantation in the
United States from 1 Jan, 2002 to 30 Jun, 2013

(HR, 1.49; 95% CI: 1.25-1.79), HCV (HR 1.30; 95% CI: 1.19-1.41) and alcoholic liver disease (HR 1.52; 95% CI:
1.19-1.94) had inferior survival compared to other ethnic groups. One of the limitations of previous studies was
the fact that they did not to adjust survival analyses for known risk factors such as donor characteristics, cold
ischemia time, recipient comorbidities and did not exclude patients whose explanted liver did not have HCC.

Therefore, we analyzed only LT recipients with confirmed HCC with the main intent of testing the null
hypothesis that after adjusting for clinical and socio-economic factors, African Americans should have
short and long-term outcomes comparable to other ethnic groups. When compared to other ethnicities, we
found that African Americans had lower education level, were more frequently affected by renal dysfunction
requiring dialysis (2.3% vs. 0.7%) and had a shorter period on the waiting list. Although 30-, 60-, 90-day
postoperative mortality was similar between African American and other ethnic groups, their 1-year
mortality was higher and their survival started to diverge from all the other ethnicities.

Only 56% of African Americans were alive after 5 years vs. 68% of Caucasians (P ≤ 0.001), 73% of Hispanics
(P ≤ 0.001) and 79%-81% of Asians and other minorities (P ≤ 0.001). Multivariate analysis confirmed that
African American ethnicity remained the strongest independent predictor of lower survival (HR 1.5; 95% CI:
1.2-1.8) after adjusting for donor and recipient age, sex, BMI, cold ischemia, diabetes and renal insufficiency,
MELD score, functional status, waiting time, level of education and UNOS region. These findings rejected
our original hypothesis that the outcomes of LT recipients with HCC should be similar among different
ethnic groups.