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Page 4 of 5 Feier. Hepatoma Res 2020;6:75 I http://dx.doi.org/10.20517/2394-5079.2020.68

donors and with expanded criteria, show excellent disease-free and overall survivals. Even in the West,
[19]
where there is a predominance of DDLT, the study by Goldaracena et al. showed that having a living
donor available had a protective effect, even if in the end, the patient is transplanted with a deceased donor.

As already stated, outcomes in LDLT for HCC can be affected by several factors, including time to
transplant, the possibility to perform the transplant in expanded criteria patients, and the possibility of the
[20]
liver regeneration adversely affecting tumor growth .
Because of the limited number of deceased donors particularly in Asian countries, patients beyond MC
were rarely submitted to DDLT. In the West, however, expanding LDLT can provide an alternative to
DDLT, allowing many centers to indicate LT for patients beyond MC. Currently, organ allocation systems
provide exception points for patients with early HCC, with favorable prognosis. As for recipients from
living donors, organ availability is driven by the living donor. In that case, usually the transplant happens
when the donor is ready, shortening the waiting time, allowing patients with more aggressive tumors to be
transplanted. We are dealing with uneven criteria to indicate LT for HCC, defining these criteria not only
on the basis of individual patient prognosis but by the fact of whether there is a living donor available.

If one looks at the results from more than a decade ago, it would be reasonable to address different selection
criteria for patients undergoing DDLT or LDLDT. However, on the basis of recent research and a better
understanding of tumor behavior, the discussion should be “how do we adequately select HCC patients for
LT?”, rather than to which transplant modality will the patient be submitted (LDLT, DDLT, Split Liver or
Domino Transplantation).

Future directions are pointing to better patient selection - looking deeper into tumor biological behavior
and addressing the presence of microvascular invasion, and not indicating LT to patients with aggressive
tumors with a worse prognosis. It is urgent to validate existing models that predict survival in LDLT
[3]
and DDLT, such as the MoRAL Score , including such criteria in the organ allocation policy, currently
[19]
restricted in many countries to the MC of 1996 . The practice reported by the Toronto group , having the
[6]
same criteria to indicate LT on the basis of patient prognosis, irrespectively if the patient will be assigned a
living or deceased donor, follows the principle of equality. After being included in the waiting list, if there
is a living donor available, the better it is for the patient and for the donor pool. If such a policy could
be embraced by Western countries, perhaps LDLT in the West could reach comparable results as those
achieved by our Asian fellows.

DECLARATIONS
Authors’ contributions
The author contributed solely to the article.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
The author declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.