Alpha‐fetoprotein Decrease from >1000 to <500 ng/ml in Patients with Hepatocellular Carcinoma Leads to Improved Post‐Transplant Outcomes

Abstract

High alpha‐fetoprotein (AFP) >1000 ng/ml is associated with poor outcome after liver transplant (LT) for hepatocellular carcinoma (HCC). A new national policy has been implemented for AFP >1000 requiring a decrease to <500 before LT, but there is a paucity of data on the optimal AFP threshold before LT. We aimed to evaluate the effects of a reduction in AFP from >1000 to different AFP thresholds before LT on survival and HCC recurrence after LT using the UNOS database. We identified 407 patients transplanted between 1/2005 and 9/2015 who had AFP >1000 at least once prior to LT. The last AFP before LT was >1000 ng/ml in 72.0%, decreased from >1000 to 101‐499 in 9.6%, and to ≤100 in 14.3%. Local regional therapy was not performed in 45.4% of patients with AFP >1000 at LT versus 12.8% of those with AFP 101‐499 and 10.3% with AFP ≤100 at LT (p<0.001). Kaplan‐Meier 5‐year post‐LT survival for those with AFP >1000 at LT was 48.8% versus 67.0% with decrease in AFP to 101‐499 (p<0.001) and 88.4% for those with AFP ≤100 at LT (p<0.001). HCC recurrence probability at 5 years was 35.0% for patients with AFP >1000 versus 13.3% for AFP of 101‐499 and 7.2% for AFP ≤100 at LT (p<0.001). In multivariable analysis, a decrease in the AFP to 101‐499 was associated with a >2 fold reduction in post‐transplant mortality (p=0.01) and a nearly 3 fold reduction in HCC recurrence (p=0.02) compared to AFP >1000 at LT.

Conclusion

Our results demonstrated significantly improved post‐LT outcome when restricting LT to patients with a reduction in AFP from >1000 to <500 ng/mL, validating the recently implemented national policy.

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