INTRODUCTION AND OBJECTIVES Clinical trials in advanced hepatocellular carcinoma (HCC) typically include patients with preserved liver function (Child-Pugh A), without adequately considering cirrhosis or clinically significant portal hypertension (CSPH). We aimed to compare prognostic models in Child-Pugh A patients. PATIENTS AND METHODS This prospective multicenter cohort study included patients with advanced HCC treated with systemic therapy (2018-2024) in Latin America. Survival was analyzed using Kaplan-Meier and Cox proportional multivariate hazards models and competing risk analysis for cause-specific mortality and hepatic decompensation. RESULTS From 306 patients receiving systemic therapy, 79.1% (n=242) were Child-Pugh A (sorafenib 60.3%, atezolizumab plus bevacizumab 30.6%, and lenvatinib 8.7%). Among these, cirrhosis was observed in 78.9%, and CSPH in 51.6%. No survival differences were observed between ALBI 1 vs 2-3 grades (HR 1.08; P=0.685), or Child-Pugh A5 vs A6. In multivariable analysis, atezolizumab plus bevacizumab was independently associated with improved OS (HR 0.64, 95% CI 0.42-0.99), adjusted for AFP ≥400 ng/mL and CSPH. Other models, including the ALBI score as a continuous or categorical variable, showed no significant independent association with mortality, nor did they improve model performance. In a competing risk regression analysis accounting for death due to tumor progression as a competing event, CSPH was the only independent variable associated with hepatic decompensation, sHR 1.98 (95% CI 1.01-3.89). CONCLUSIONS Accurate reporting of cirrhosis and CSPH is essential, even for Child-Pugh A patients, as both are independent prognostic factors that should be considered for therapeutic decision-making in advanced HCC.
INTRODUCTION AND OBJECTIVES Long-term outcomes after simultaneous liver-kidney transplantation (SLKT) are incompletely characterized. We aimed to estimate overall survival, survival with functioning grafts, kidney graft function over time, and temporal trends in SLKT practice. PATIENTS AND METHODS Retrospective multicenter cohort of adults undergoing SLKT between 2003 and 2025 across 21 transplant centers in 7 Latin American countries. Overall survival and survival with functioning grafts were estimated up to 10 years after transplantation. Outcomes, recipient and donor characteristics were described across transplant eras. RESULTS Among 305 SLKT recipients, cirrhosis was the main liver indication (67.9%), whereas chronic kidney disease was the main renal indication (93.1%), most commonly due to polycystic kidney disease. Recipient profiles evolved over time toward greater metabolic burden, with more diabetes and MASLD, and increasing use of MELD exceptions - primarily for hepatocellular carcinoma - compared with earlier transplant eras. Overall survival was 78.5% at 1 year and 57.3% at 10 years, with 1-year survival exceeding 90% in 2022-2025; survival with functioning grafts was 77.4% and 50.9%, respectively. Early mortality predominated: 64% of deaths occurred in the first year, mainly due to bacterial infections (39%). Median eGFR among survivors remained in the mid-60s through 10 years. CONCLUSIONS SLKT achieved acceptable long-term patient, graft, and kidney function outcomes, with improved 1-year survival in recent eras. Early mortality remained concentrated in the first year and was often infection-related, highlighting an important target for post-transplant care as recipient metabolic complexity increases. These multicenter data provide long-term benchmarks to inform counseling and program planning amid an evolving metabolic burden.
