Characterization of Current Utilization of Machine Perfusion and Living-Donor Liver Transplantation for Hepatocellular Carcinoma.

BACKGROUND: Patients diagnosed with hepatocellular carcinoma (HCC) have experienced a decreased rate of deceased-donor transplants. We aimed to examine differences between two alternative approaches: living-donor liver transplantation (LDLT) and machine perfusion (MP). METHODOLOGY: Using national data, we identified 935 patients who underwent liver transplantation for a primary diagnosis of HCC between January 1, 2017, and December 31, 2023, using either MP or LDLT. RESULTS: A total of 537 patients were transplanted using MP compared with 398 with LDLT. Throughout the study period, patients transplanted using MP were more likely to be older (odds ratio (OR) 1.03, P < 0.01), obese (OR 1.53, P = 0.02), and diabetic (OR 1.62, P = 0.01) compared with those who received LDLT. Additionally, those receiving MP were less likely to have moderate (OR 0.1, P < 0.01) or good (OR 0.1, P < 0.01) function status. Despite a worse preoperative condition, patients with MP had a significantly shorter length of stay than those who underwent LDLT (mean 9.6 days vs. 15.8 days, P < 0.01) with comparable graft failure rates (MP 3.1% vs. LDLT 3.6%, P = 0.7). Additionally, in those patients with available follow-up data, rehospitalization rates were similar between the two groups (MP 43.8% vs. LDLT 43.3%, P = 0.89). CONCLUSIONS: Increased competition for organs after the implementation of acuity circle allocation has resulted in decreased rates of transplantation for HCC. LDLT has been one solution to increase access and remains a viable option for some patients. Conversely, MP may help centers offer organs to patients who are non-ideal living donor candidates without concern for worse outcomes.