Beyond rejection risk: Identifying ideal candidates for pretransplant immune checkpoint inhibitors for HCC.
Laia Aceituno, Grainne M O'Kane, Woo Jin Choi et al.
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In 30 seconds
This systematic review assessed immune checkpoint inhibitors (ICIs) used as bridging or downstaging therapy before liver transplantation for hepatocellular carcinoma. It included 39 studies and 261 patients, with outcomes synthesized descriptively and exploratory regression analyses performed. Post-transplant HCC recurrence occurred in 18.6%, while allograft rejection occurred in 23.0%. Shorter ICI exposure was associated with greater recurrence risk; spline analyses indicated that treatment benefit was achieved at 80 days. The authors also found that a washout period shorter than 50 days was associated with increased rejection risk.
Key findings
- Post-transplant HCC recurrence occurred in 18.6% of patients; allograft rejection occurred in 23.0%.
- Shorter ICI exposure was associated with higher recurrence risk (OR: 0.9; p <0.001); spline models indicated benefit at 80 days.
- A shorter washout period (<50 d) was independently associated with increased rejection risk.
- Allograft rejection led to graft failure in 14.7% of patients.
Why it matters
Pretransplant ICI use presents competing oncologic and graft-related risks. These findings suggest that treatment duration and the interval between the last ICI dose and transplantation may be relevant to recurrence and rejection outcomes. The review also highlights uncertainty about candidate selection and the need to interpret these associations cautiously when considering ICI use around transplantation.
What to keep in mind
The evidence came from published studies and was synthesized descriptively; the abstract does not report randomized comparisons. The exploratory analyses and proposed timing thresholds therefore require confirmation.