Living vs. deceased donor liver transplantation for hepatocellular carcinoma: a systematic review and meta-analysis Grant RC, Sandhu L, Dixon PR, Greig PD, Grant DR, McGilvray ID. Living vs. deceased donor liver transplantation for hepatocellular carcinoma: a systematic review and meta-analysis. Abstract: Experimental studies suggest that the regenerating liver provides a “fertile field” for the growth of hepatocellular carcinoma (HCC). However, clinical studies report conflicting results comparing living donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT) for HCC. Thus, disease-free survival (DFS) and overall survival (OS) were compared after LDLT and DDLT for HCC in a systematic review and meta-analysis. Twelve studies satisfied eligibility criteria for DFS, including 633 LDLT and 1232 DDLT. Twelve studies satisfied eligibility criteria for OS, including 637 LDLT and 1050 DDLT. Altogether, there were 16 unique studies; 1, 2, and 13 of these were rated as high, medium, and low quality, respectively. Studies were heterogeneous, non-randomized, and mostly retrospective. The combined hazard ratio was 1.59 (95% confidence interval [CI]: 1.02–2.49; I 2 = 50.07%) for DFS after LDLT vs. DDLT for HCC, and 0.97 (95% CI: 0.73–1.27; I 2 = 5.68%) for OS. This analysis provides evidence of lower DFS after LDLT compared with DDLT for HCC. Improved study design and reporting is required in future research to ascribe the observed difference in DFS to study bias or biological risk specifically associated with LDLT. Robert C. Grant, Lakhbir Sandhu, Peter R. Dixon, Paul D. Greig, David R. Grant and Ian D. McGilvray Department of Surgery, University of Toronto, Toronto, ON, Canada Key words: hepatocellular carcinoma – liver transplantation – meta-analysis Corresponding author: Ian D. McGilvray, MD, FRCSC, Surgery, Toronto General Hospital, 585 University Avenue, 11C1250 NCSB, Toronto, ON M5G 2N2, Canada. Tel.: 416 340 5230; fax: 416 340 5242; e-mail: Ian.McGilvray@uhn.on.ca Conflict of interest: None. Accepted for publication 6 August 2012 In the United States, the incidence of hepatocel- lular carcinoma (HCC) has increased annually by 4.3% since 1992 to the current rate of 5.1 per 100 000, with a one-yr survival rate of only 47% (1). Liver transplantation is often the optimal curative treatment for HCC (2). Unlike other treatment modalities, liver transplantation corrects underlying liver dysfunction and removes the diseased tissue that poses a risk for the devel- opment of additional future HCC (3). Unfortu- nately, the need for donor livers exceeds organ availability in most countries. For example, in the United States, over 18 000 people await deceased donor livers annually, while only approximately 5000 are available (4). This short- age is likely to worsen; liver donation in the Uni- ted States has been declining (5), while HCC incidence has increased (1). In the past decade, living donor liver transplan- tation (LDLT) has received interest as an alterna- tive to deceased donor liver transplantation (DDLT). LDLT alleviates the shortage of donor livers and may allow for the expansion of recipient criteria (6). However, animal studies suggest that the regenerating liver provides a “fertile field” for the recurrence of HCC after transplantation (7, 8). Clinical studies report mixed results when compar- ing LDLT and DDLT: some conclude that LDLT is an inferior “cancer curing” treatment (9–11), while others report no significant differences between the procedures (3, 6, 9–19). In this study, a systematic review and meta-anal- ysis were performed to assess the current evidence comparing disease-free survival (DFS) and overall survival (OS) after LDLT and DDLT for HCC. Methods The methods for the systematic review and meta- analysis were defined a priori as outlined below. 140 © 2012 John Wiley & Sons A/S Clin Transplant 2013: 27: 140–147 DOI: 10.1111/ctr.12031