Mikel Gastaca

Background: Patients living with human immunodeficiency virus (HIV) infection have been gradually accepted as solid organ transplant recipients, although there is still concern that the burden of immunosuppression and HIV infection could increase the risk of post-transplant cancer. Methods: The risk of de novo cancer was evaluated in a prospective cohort of 272 HIV-positive and 816 matched HIV-negative liver transplant recipients in Spain (2002–2012). All tumors, except hepatocellular carcinoma recurrence and non-melanoma skin cancer, after liver transplant were considered as events and death as competing event in this study. Results: Despite matching, patients with HIV were significantly younger (45.8 vs 49.3 years). Sixteen (5.9%) patients with HIV and 61 (7.5%) HIV-negative patients developed de novo cancers (P = .39) after a median follow-up of 59.8 and 72.3 months, respectively. The most frequently diagnosed types of tumors were non-Hodgkin lymphoma (n = 19), lung cancer (n = 14), and head and neck cancer (n = 14). Time of onset, distribution, and tumor stage at diagnosis were similar in both groups. The cumulative incidences of de novo cancer at 5 and 10 years were, respectively, 6% and 12% in patients with HIV and 6% and 13% in uninfected patients. Survival after cancer diagnosis did not differ between groups. The only factor related to the development of de novo cancers was a higher age at transplantation. Conclusions: Human immunodeficiency virus infection per se is not associated to a higher risk of de novo cancer after liver transplantation.

Background and Aims: Although GEMA‐Na outperforms MELD 3.0 for liver allocation, concerns about the subjectivity of its ascites component persist. We compared the performance of a GEMA‐Na iteration that excludes ascites with other allocation scores. Approach and Results: A multinational cohort study was conducted, including adult candidates for elective liver transplantation in the UK (2010–2020), Australia (1998–2020), and Spain (2016–2021). The primary outcome was mortality or delisting for sickness within 90 days. The prognostic impact of ascites was evaluated using multivariable Cox's regression. Discrimination was assessed using Harrell's c‐statistics (Hc). The study included 15 391 patients (28.5% women). The prevalence of the primary outcome was 5.8% in the UK, 5.3% in Australia, and 4.7% in Spain. The presence and severity of ascites was associated with an incremental risk of the primary outcome: 3.3% without ascites, 5.8% with mild ascites, and 7.7% with moderate–severe ascites ( p < 0.001). Removal of ascites from the GEMA‐Na score resulted in a one‐point reduction in 18% of patients (52.4% of patients with moderate–severe ascites). GEMA‐Na without ascites showed only a marginal decrease in discrimination (Hc = 0.755 vs. Hc = 0.753; p = 0.007) but still significantly outperformed MELD 3.0 (Hc = 0.734; p < 0.001) and MELD‐Na (Hc = 0.737; p < 0.001). In women, GEMA‐Na with and without ascites demonstrated comparable discrimination (Hc = 0.784 vs. Hc = 0.783; p = 0.61), both outperforming MELD 3.0 (Hc = 0.750; p < 0.001), and MELD‐Na (Hc = 0.749; p < 0.001). Conclusions: Despite the prognostic impact of ascites among liver transplant candidates, GEMA‐Na without ascites outperformed other scores in predicting wait‐list outcomes and may be used wherever the inclusion of ascites is considered too subjective.

Background/Objectives: Despite the long-standing history of liver transplantation (LT) in Spain, no multicenter study has reviewed national outcomes for LT in metastatic neuroendocrine tumors (NETs). In the current era of transplant oncology, auditing these results is essential to refine patient selection and improve long-term outcomes. Methods: This retrospective observational study analyzed data from 13 centers, including 91 patients who underwent LT for NET between 1995 and 2024. Patients were stratified into two groups: Milan IN (those meeting the Milan criteria) and Milan OUT (the remainder). Results: Recurrence occurred in 57.1% of cases, and overall mortality was 51.6%. Of the 91 patients, 71 (78.0%) were Milan IN and 20 (22.0%) were Milan OUT. Five-year overall survival was 71.0% in Milan IN and 58.0% in Milan OUT, with a statistically significant difference. The 5-year disease-free survival (DFS) rate was 58.8% in Milan IN and 36.3% in Milan OUT; this difference was not statistically significant. Conclusions: In conclusion, strict adherence to Milan criteria and incorporation of modern prognostic factors are critical to optimize long-term survival in LT for NET. While the overall outcomes in this historical cohort are modest, future improvements are expected through more rigorous selection and the potential use of bridging or downstaging therapies.

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