Skip to main content
SpringerLink
Log in

Liver-allocation policies for patients affected by HCC in Europe

  • Liver Transplantation (D Mulligan, Section Editor)
  • Published:
Current Transplantation Reports Aims and scope Submit manuscript

Abstract

The main goal of organ-allocation systems is to guarantee equal access to the limited resource of liver grafts for every patient on the waiting list, striking a balance between the ethical principles of equity, utility, benefit, need, and fairness. The European healthcare scenario is very complex, as it is essentially decentralized, and each nation—and region inside the nation—operates with a significant degree of autonomy. Furthermore, the epidemiology of liver diseases and hepatocarcinoma (HCC) differs between European countries and clearly affects indications and priorities. The aims of this review were to analyze the liver-allocation policies for HCC in different European countries. The European area considered for this analysis included five macro-areas or countries with similar liver-sharing and allocation policies: Centro Nazionale Trapianti (CNT) in Italy; Eurotransplant (Germany, the Netherlands, Belgium, Luxembourg, Austria, Hungary, Slovenia, and Croatia); Organizacion Nacional de Transplantes (ONT) in Spain; Etablissement français des Greffes (EfG) in France; NHS Blood & Transplant (NHSBT) in the UK and Ireland; and Scandiatransplant (Sweden, Norway, Finland, Denmark, and Iceland). Each area identified as a network for organ sharing in Europe adopts an allocation system based on either a center-oriented or a patient-oriented policy. Worldwide, two primary principles dominate the priorization of patients with HCC on the waiting list for deceased-donor liver transplant: urgency and utility. Although no common organ-allocation policy for European countries exists, long-term survival rates for patients with HCC on the transplant waiting lists are comparable to those reported in the United Network for Organ Sharing (UNOS) register. However, as allocation principles are discussed, new proposals emerge, and the epidemiology of liver disease changes, we strongly recommend steps are taken toward a common system.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: ••Of major importance

  1. Ringe B, Pichlmayr R, Tusch G. Surgical treatment of hepatocellular carcinoma: experience with liver resection and transplantation in 198 patients. World J Surg. 1991;15(2):270–85.

    Article  CAS  PubMed  Google Scholar 

  2. Ryder SD. Guidelines for the diagnosis and treatment of hepato- cellular carcinoma (HCC) in adults. Gut. 2003;52 Suppl 3: p. iii1-iii8.

  3. Mazzaferro V et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med. 1996;334(11):693–9.

    Article  CAS  PubMed  Google Scholar 

  4. Adam R et al. Evolution of indications and results of liver transplantation in Europe. A report from the European Liver Transplant Registry (ELTR). J Hepatol. 2012;57(3):675–88. doi:10.1016/j.jhep.2012.04.015.

    Article  PubMed  Google Scholar 

  5. Ioannou GN, Perkins JD, Carithers Jr RL. Liver transplantation for hepatocellular carcinoma: impact of the MELD allocation system and predictors of survival. Gastroenterology. 2008;134(5):1342–51.

    Article  PubMed  Google Scholar 

  6. Toso C, Majno P, Berney T, Morel P, Mentha G, Combescure C. Validation of a dropout assessment model of candidates with/without hepatocellular carcinoma on a common liver transplant waiting list. Transplant Int. 2014;27:686–95.

    Article  Google Scholar 

  7. Merani S, Majno P, Kneteman NM, et al. The impact of waiting list alpha-fetoprotein changes on the outcome of liver transplant for hepatocellular carcinoma. J Hepatol. 2011;55:814–9.

    Article  CAS  PubMed  Google Scholar 

  8. Toso C, Mentha G, Majno P. Liver transplantation for hepatocellular carcinoma: Five steps to prevent recurrence. Am J Transplant. 2011;11:2031–5.

    Article  CAS  PubMed  Google Scholar 

  9. Toso C, Mazzaferro V, Bruix J, et al. Toward a better liver graft allocation that accounts for candidates with and without hepatocellular carcinoma. Am J Transplant. 2014;14(10):2221–7.

    Article  CAS  PubMed  Google Scholar 

  10. Merion RM, Schaubel DE, Dykstra DM, Freeman RB, Port FK, Wolfe RA. The survival benefit of liver transplantation. Am J Transplant. 2005;5:307–13.

    Article  PubMed  Google Scholar 

  11. Schaubel DE, Sima CS, Goodrich NP, Feng S, Merion RM. The survival benefit of deceased donor liver transplantation as a function of candidate disease severity and donor quality. Am J Transplant. 2008;8:419–25.

    Article  CAS  PubMed  Google Scholar 

  12. Cillo U, Vitale A, Volk ML, et al. The survival benefit of liver transplantation in hepatocellular carcinoma patients. Dig Liver Dis. 2010;42:642–9.

    Article  PubMed  Google Scholar 

  13. Ravaioli M, Grazi GL, Ercolani G, et al. Liver allocation for hepatocellular carcinoma: A European center policy in the pre-MELD era. Transplantation. 2006;81:525–30.

    Article  PubMed  Google Scholar 

  14. Ravaioli M, Grazi GL, Ballardinin G, et al. Liver transplantation with the Meld system: a prospective study from a single European center. Am J Transplant. 2006;6:1572–7.

    Article  CAS  PubMed  Google Scholar 

  15. Vitale A, Volk ML, De Feo TM, et al. A method for establishing allocation equity among patients with and without hepatocellular carcinoma on a common liver transplant waiting list. J Hepatol. 2014;60:290–7. This article provides the first model in which HCC and non-HCC patients are equally prioritized according to transplant benefit.

    Article  PubMed  Google Scholar 

  16. Eurotransplant manual. Chap 5. Available at www.eurotransplant.org

  17. Ramos RE, Ortiz de Urbina J, Santoyo Santoyo J, et al. Degree of uniformity in the treatment of hepatocellular carcinoma in the Spanish teams of liver transplantation [Spanish]. Med Clin (Barc). 2013;141(9):406–10.

    Article  Google Scholar 

  18. V Consensus Meeting of the Spanish Society for Liver Transplant on high-risk recipients, immunosupression scenarios and management of hepatocarcinoma on the transplant waiting list. Cir Esp. 2015;93(10):619-37. doi: 10.1016/j.ciresp.2015.04.007

  19. Francoz C et al. Model for end-stage liver disease exceptions in the context of the french model for end-stage liver disease score-based liver allocation system. Liver Transpl. 2011;17:1137–51.

    Article  PubMed  Google Scholar 

  20. Barber KM, Pioli S, Blackwell JE, et al. Development of a UK score for patients with end-stage liver disease. Hepatology. 2007;46:510A.

    Google Scholar 

  21. Menon KV, Hakeem AR, Heaton ND. Review article: liver transplantation for hepatocellular carcinoma - a critical appraisal of the current worldwide listing criteria. Aliment Pharmacol Ther. 2014;40(8):893–902.

    Article  CAS  PubMed  Google Scholar 

  22. Fosby B et al. Liver transplantation in the nordic countries - an intention to treat and post-transplant analysis from the nordic liver transplant registry 1982-2013. Scand J Gastroenterol. 2015;50(6):797–808. doi:10.3109/00365521.2015.1036359.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Shukla A et al. Liver transplantation: east versus west. J Clin Exp Hepatol. 2013;3(3):243–53. doi:10.1016/j.jceh.2013.08.004.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Cillo U, Burra P, Mazzaferro V, et al. A multistep, consensus-based approach to organ allocation in liver transplantation: toward a “blended principle model”. Am J Transplant. 2015;15:2552–61.

    Article  CAS  PubMed  Google Scholar 

  25. Mazzaferro V. Squaring the circle of selection and allocation in liver transplantation for HCC: an adaptive approach. Hepatology. 2016;63(5):1707–17. This is a new perspective of patients’ priority for liver tranplantation due to HCC. This model is able to contemplate together tumor size and number, tumor response to the locoregional treatments, and feasibility of pre-transplant treatments.

    Article  PubMed  PubMed Central  Google Scholar 

  26. De Giorgio M, Vezzoli S, Cohen E, Armellini E, Lucà MG, Verga G, et al. Prediction of progression-free survival in patients presenting with hepatocellular carcinoma within the Milan criteria. Liver Transpl. 2010;16(4):503–12.

    PubMed  Google Scholar 

  27. De Carlis L, Di Sandro S, Giacomoni A, Slim A, Lauterio A, Mangoni I, et al. Beyond the Milan criteria: what risks for patients with hepatocellular carcinoma progression before liver transplantation? J Clin Gastroenterol. 2012;46(1):78–86.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

This work was in part supported by Liver Center Grant P30DK034989 (to MS).

Author information

Authors and Affiliations

  1. Department of Medicine and Surgery, International Center for Digestive Health, University of Milan-Bicocca, Via Cadore, 48, Monza, Milan, Italy

    Luciano De Carlis, Stefano Okolicsanyi & Mario Strazzabosco

  2. Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, Milan, Italy

    Luciano De Carlis, Stefano Di Sandro, Leonardo Centonze, Andrea Lauterio, Vincenzo Buscemi, Riccardo De Carlis, Fabio Ferla, Raffaella Sguinzi & Luca Belli

  3. Department of Surgical Sciences, University of Pavia, Pavia, Italy

    Stefano Di Sandro, Vincenzo Buscemi & Riccardo De Carlis

  4. Liver Center, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA

    Mario Strazzabosco

Authors
  1. Luciano De Carlis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stefano Di Sandro
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Leonardo Centonze
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Andrea Lauterio
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Vincenzo Buscemi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Riccardo De Carlis
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Fabio Ferla
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Raffaella Sguinzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Stefano Okolicsanyi
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Luca Belli
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Mario Strazzabosco
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mario Strazzabosco.

Ethics declarations

Conflicts of Interest

Mario Strazzabosco, Stefano Okolicsanyi, Vincenzo Buscemi, Leonardo Centonze, Luciano De Carlis, Riccardo De Carlis, Stefano Di Sandro, Fabio Ferla, Andrea Lauterio, Raffaella Sguinzi, and Luca Saverio Belli have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Liver Transplantation

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

De Carlis, L., Di Sandro, S., Centonze, L. et al. Liver-allocation policies for patients affected by HCC in Europe. Curr Transpl Rep 3, 313–318 (2016). https://doi.org/10.1007/s40472-016-0117-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40472-016-0117-6

Keywords

Search

Navigation