Benefit and harm of deceased- or living-donor liver transplantation for hepatocellular carcinoma

The decision to allocate a given organ from a deceased (DD) or living donor (LD) to a particular recipient awaiting liver transplantation (LT) is strongly influenced by ethical and health policy issues. The liver transplant community is currently discussing several ethical principles with a view to improving the allocation process as a whole. These principles are: urgency, utility, intention-to-treat survival, transplant benefit, harm to candidates on waiting list (WL), harm to living donors, chances of re-transplantation. The potential conflict between different principles is particularly relevant for patients with hepatocellular carcinoma (HCC) for a number of reasons: (a) candidates for LT with HCC are increasing; (b) the HCC population varies considerably in prognostic terms; (c) tumor progression before LT in HCC patients may significantly impair post-LT outcome; and (d) effective alternatives to LT are often available for treating HCC patients. In this paper, we propose a model for effectively representing the potential equipoise achievable between the different ethical principles involved in LT. We considered a triangle with transplant benefit (life expectancy with LT minus that without LT) at its superior apex, and potential harm to candidates on the WL and living donor at the inferior apices. The model may be helpful in clinical decision-making regarding LT: (1) by modulating the relative prognostic weight of different ethical principles involved in the relationship between transplant benefit and harm to candidates on the WL; and (2) by simplifying the decision between DDLT and LDLT in a given geographical setting.