LETTER TO THE EDITORS

Is There an Ideal Cutoff for a-Fetoprotein as anExclusion Criterion for Liver Transplantation?

Received June 29, 2014; accepted July 2, 2014.

TO THE EDITORS:

Hameed et al.1 published a study on a-fetoprotein(AFP) as an exclusion criterion for liver transplanta-tion (LT) in patients with hepatocellular carcinoma(HCC). We believe that they used a very high cutoff forAFP (>1000 ng/mL). Because of the retrospectivenature of the study and the small sample with ele-vated AFP levels, we believe that it is difficult to takethis value as definitive.

We conducted a retrospective study of 768 patientsundergoing LT between 1997 and 2010 (206 with ahistological diagnosis of HCC). The leading cause ofcirrhosis was also hepatitis C. Patients were followedfor up to 173 months (mean 5 49.8 months). The sur-vival of LT recipients at 1, 3, 5, and 14 years was78.6%, 65.4%, 60.5%, and 38.7%, respectively. Sur-vival was higher in the recurrence-free group versuspatients with HCC recurrence (P<0.001), and AFPlevels correlated with tumor recurrence. At the 5-yearposttransplant follow-up, the rate of HCC recurrencein patients with AFP levels<50 ng/mL was 13.1%,whereas the rates were 29.4% for AFP levels of 50 to200 ng/mL and 36.8% for AFP levels >200 ng/mL(P 5 0.002). A univariate analysis of risk factors forHCC recurrence revealed a hazard ratio (HR) of 3.85[95% confidence interval (CI) 5 1.66-8.93, P 5 0.002]for AFP levels�200 ng/mL. Other risk factors forrecurrence were the number of tumors (HR 5 1.37,95% CI 5 1.20-1.56, P<0.001), the degree of differen-tiation (HR 5 2.28, 95% CI 5 1.18-4.39, P 5 0.014),vascular invasion (HR 5 4.82, 95% CI 5 2.08-11.17,P<0.001), and the presence of satellite nodules(HR 5 3.33, 95% CI 5 1.66-6.68, P 5 0.001). In a mul-tivariate analysis, only AFP levels>200 ng/mL

remained a risk factor with an HR of 3.32 (95%CI 5 1.40-7.91, P 5 0.007).

Despite the diversity of values reported in the litera-ture,2-4 we believe that very high levels of AFP (>1000ng/mL) are restrictive because of the small number ofpatients who meet this criterion and the need for abetter standard for organ allocation.

Angelo Alves de Mattos, Ph.D.Luciana dos Santos Schraiber, M.D.

Maria Lucia Zanotelli, Ph.D.

Guido Cantisani, M.D.

GastroenterologyUniversidade Federal de Ciencias da

Sa�ude de Porto Alegre HospitalSanta Casa de Porto Alegre, Rio Grande do Sul, Brazil

REFERENCES

1. Hameed B, Mehta N, Sapisochin G, Roberts JP, Yao FY.Alpha-fetoprotein>1000 ng/mL as an exclusion criterionfor liver transplantation in patients with hepatocellularcarcinoma meeting the Milan criteria. Liver Transpl2014;20:945-951.

2. Vibert E, Azoulay D, Hoti E, Iacopinelli S, Samuel D,Salloum C, et al. Progression of alphafetoprotein beforeliver transplantation for hepatocellular carcinoma in cir-rhotic patients: a critical factor. Am J Transplant 2010;10:129-137.

3. Duvoux C, Roudot-Thoraval F, Decaens T, Pessione F,Badran H, Piardi T, et al. Liver transplantation for hepa-tocellular carcinoma: a model including a-fetoproteinimproves the performance of Milan criteria. Gastroenter-ology 2012;143:986-994.

4. Berry K, Ioannou GN. Serum alpha-fetoprotein level inde-pendently predicts posttransplant survival in patientswith hepatocellular carcinoma. Liver Transpl 2013;19:634-645.

Address reprint request to Angelo Alves de Mattos, Gastroenterology, Universidade Federal de Ciencias da Sa�ude de Porto Alegre, Porto Ale-gre, Rio Grande do Sul, Brazil. E-mail: angeloamattos@gmail.com

DOI 10.1002/lt.23954View this article online at wileyonlinelibrary.com.LIVER TRANSPLANTATION. DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases

LIVER TRANSPLANTATION 20:1284, 2014

VC 2014 American Association for the Study of Liver Diseases.