Long-term outcomes in deceased versus living donor liver transplantation for hepatocellular carcinoma: a bi-institutional study of 486 cases

Background: Liver transplantation (LT) is a curative treatment for hepatocellular carcinoma (HCC), but access is often limited by organ shortage and prolonged waiting times. Living donor liver transplantation (LDLT) offers timely transplantation and may improve oncologic outcomes compared to deceased donor liver transplantation (DDLT). Methods: This retrospective cohort study included 486 patients with HCC who underwent LT at two high-volume centers between 2010 and 2020. Outcomes were compared between LDLT and DDLT recipients. Survival analyses were performed using Kaplan–Meier estimates and Cox regression models. Results: A total of 182 patients received LDLT and 304 received DDLT. Baseline tumor burden and liver function were comparable. LDLT was associated with shorter time to transplant (186 vs. 410 days, p < 0.001), fewer downstaging procedures, and improved survival. Five-year overall survival was 82% for LDLT versus 73% for DDLT (p = 0.010); disease-free survival was 93% versus 83% (p = 0.003). On multivariable analysis, DDLT (HR 3.03, p = 0.017) and BCLC B/C stage (HR 1.98, p = 0.017) were independent predictors of recurrence. Conclusion: LDLT is associated with superior long-term outcomes in patients with HCC, independent of tumor stage and timing. These findings support the broader use of LDLT as an effective oncologic strategy.