Liver Transplantation after Immune Checkpoint Inhibition in HCC Patients: Insights from an International Multicenter Registry

Introduction: The use of immune checkpoint inhibitors (ICI) for hepatocellular carcinoma (HCC) has become standard in advanced stage and in selected cases also in intermediate stage (BCLC B) HCC. In suitable BCLC B patients with good tumor response upon ICI treatment, liver transplantation (LTx) without standard exception for HCC can be considered. However, the feasibility of LTx after ICI therapy remains debated due to the risk of potentially fatal allograft rejection. To analyze the outcome of LTx following ICI therapy, a multicenter registry was established.

Methods: Data from HCC patients transplanted after ICI treatment were collected from nine European transplant centers. Documentation included patient and tumor characteristics, ICI regimens, time between ICI and LTx, and adverse events. Overall and rejection-free survival rates were assessed using the log-rank test.

Results: Twelve patients underwent LTx for HCC after ICI therapy. Most patients (10/12) received Atezolizumab/Bevacizumab. 12-months survival rate was 78% (7/9) with a median follow-up of 508 days. Three rejection episodes were documented: one fatal rejection 21 days after LTx and two non-fatal rejections at 8 days and five months, both successfully managed with an increase in immunosuppressive therapy. Importantly, the fatal rejection correlated with a brief ICI wash-out of only 13 days.

Conclusion: A 25% overall rejection rate was observed in LTx patients after ICI. Importantly, the interval between ICI and LTx seems to be a predictor of rejection severity. This study shows that LTX following ICI therapy is safe for patients as long if sufficient ICI wash-out is considered.

Publication History

Article published online:
20 January 2025