Survival outcomes of patients after liver transplantation for patients with hepatocellular carcinoma exceeding the Hangzhou criteria.

Background: Patient selection is one of the key factors influencing prognosis after liver transplantation (LT), and a number of selection criteria have been proposed and broadly applied. The benefit of LT is debatable when patients exceed these criteria in light of liver worldwide donor shortage. This study aims to identify key prognostic indicators predicting patients undergoing LT beyond Hanzhou criteria, to guide LT candidate selection. Methods: The clinical data and pathological findings of patients who underwent LT in the Liver Transplantation Center of General Hospital of Southern Theater Command from September 2003 to August 2017 were collected for retrospective analysis, only patients exceeding the Hangzhou criteria were enrolled. Patients were followed up until December 1, 2023; disease-free survival (DFS) and overall survival (OS) was analyzed; and predictive models of DFS and OS were constructed and validated. Results: A total of 161 patients were included in the analysis. A tumor diameter ≥6 cm [hazard ratio (HR) =2.01; P=0.01], alpha fetoprotein (AFP) levels >1,000 ng/mL (HR =2.68; P<0.001), lack of metformin administration (HR =2.98; P=0.008), operative blood loss >2,000 mL (HR =1.75; P=0.01), and female donor gender (HR =3.71; P=0.004) were independent risk factors for lower DFS, while a tumor diameter ≥6 cm (HR =2.05; P=0.001), AFP level >1,000 ng/mL (HR =1.54; P=0.04), and female donor gender (HR =4.45; P<0.001) were independent predictors of worse OS. Patients with a preoperative AFP level ≤1,000 ng/mL or a history of metformin administration had a significantly better prognosis after LT. Conclusions: For patients exceeding the Hangzhou criteria, those with an AFP level ≤1,000 ng/mL can still achieve acceptable long-term prognosis after LT. Administration of metformin has a strong positive association with longer recurrence-free survival. The patient criteria for selection for LT can be tentatively expanded.