1. A2ALL When Using A2ALL Slides We welcome the use of A2ALL slides, as we value the distribution of our research for the benefit of patient care and transplant research. Because the A2ALL data and analyses on the following slides are published in the public domain, we ask that you honor the following guidelines when using A2ALL slides for your own research and presentations.

2. A2ALL A2ALL Slide Use Guidelines Modifying A2ALL data, analyses, tables, or graphics in any form is not permitted without prior approval from the A2ALL coordinating center staff at University of Michigan/Arbor Research. Each A2ALL slide used must include the citation of the associated publication and feature the corresponding A2ALL logo.

3. A2ALL Provides valuable information on the outcomes of adult-to-adult living donor liver transplants (AALDLT) at 9 transplant centers, enrolled from 1998 through present Receives oversight and funding from the National Institutes of Health (NIH), a division of the U.S. Department of Health and Human Services Coordinated by the Arbor Research Collaborative for Health together with the University of Michigan, Ann Arbor, MI, USA For more information, visit http://nih-a2all.org/ A2ALL Background

4. A2ALL Outcomes of Living and Deceased Donor Liver Transplant Recipients with Hepatocellular Carcinoma: Results of the A2ALL Cohort L. M. Kulik, R. A. Fisher, D.R. Rodrigo, R. S. Brown, Jr., C. E. Freise, A. Shaked, J.E. Everhart, G. T. Everson, J. C. Hong, P. H. Hayashi, C. L. Berg, A. S. F. Lok and the A2ALL Study Group Am J Transplant. 2012 Nov;12(11):2997-3007 Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

5. A2ALL Background The use of living donor liver transplantation (LDLT) shortens waiting time in patients with hepatocellular carcinoma (HCC), but the rate of recurrent HCC had been reported to be higher after LDLT compared to deceased donor liver transplant (DDLT). Overall survival rates had been reported to be similar between LDLT and DDLT. Factors responsible for increased HCC recurrence in LDLT are speculative. The Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) reported a 3-year HCC recurrence was higher in LDLT recipients based on retrospective data. Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

6. A2ALL Specific Aims To determine if there is a difference in patients with HCC receiving LDLT versus DDLT in the A2ALL Prospective Cohort Study in the MELD Era: - HCC recurrence rate - Survival rate after liver transplant - Recurrence-free survival rate To determine survival benefit of receiving LDLT compared to non-LDLT Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

7. A2ALL Study Population and Data Collection 229 patients diagnosed with HCC prior to transplant across the 9 A2ALL centers were included. Data were obtained using retrospective chart review from 01/01/1998 to 02/28/2003 and a combination of retrospective and prospective collection from 02/28/2003 through 08/31/2010. Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

8. A2ALL Methods Primary outcomes were HCC recurrence, overall survival, and recurrence-free survival from time of transplant. Kaplan-Meier estimates were computed and Cox regression was used to assess predictors of the three outcomes. –Predictors tested included transplant type, recipient age, race, AFP, Model for End-Stage Liver Disease (MELD) score, number of loco-regional therapy (LRT), pre/post MELD era, waiting time, etiology of cirrhosis, and explant characteristics. Sequential stratification from the time of donor evaluation was used to determine overall survival in LDLT versus non-LDLT. Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

9. A2ALL Table 1. Characteristics of HCC patients at evaluation of the first living donor (1/2) Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

10. A2ALL Table 1. Characteristics of HCC patients at evaluation of the first living donor (2/2) Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

11. A2ALL LDLT (n=100)DDLT (n=97) Characteristics † Mean ± SD or % p-value ‡ At Transplant AFP (ng/mL)0.0065 <204859 20-4003136 >400215 Log AFP 1.7 ± 1.11.2 ± 0.7 0.0003 Donor Age (years) 35.0 ± 10.242.3 ± 17.7 0.0019 Cold Ischemia Time (minutes) 65.6 ± 60.4409 ± 195 <0.0001 MELD 13.3 ± 4.613.8 ± 6.4 0.5067 Beyond Milan52260.0003 Beyond UCSF35140.0015 HCC ablation from donor evaluation to LT31490.0102 HCC ablation ever before LT59730.0355 No. of ablations since diagnosis 1.2 ± 1.51.8 ± 1.7 0.0137 Days from donor evaluation to LT77.7 ± 106180.5 ± 2580.0004 Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

12. A2ALL LDLT (n=100)DDLT (n=97) Characteristics † Mean ± SD or % p-value ‡ Explant Pathology Tumor stage0.2441 T0613 T1712 T231 T33524 T42120 Beyond Milan56440.0963 Beyond UCSF48340.0573 Bilobar HCC42330.2160 Diameter of largest nodule (cm) 4.3 ± 2.53.5 ± 1.9 0.0140 No. of tumor nodules 2.4 ± 1.82.1 ± 1.7 0.3189 Vascular invasion23120.0658 Total Length of Nodules (cm)6.4± 4.05.4± 3.30.0906 Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007 Table 2. Characteristics of HCC patients at transplant (2/3)

13. A2ALL LDLT (n=100)DDLT (n=97) Characteristics † Mean ± SD or % p-value ‡ Explant Pathology Tumor grade0.9719 G129 G25453 G31618 † Number of missing values for [LDLT, DDLT] were: [14,12] for AFP, [1,24] for donor age, [23,3] for cold ischemia time, [9,3] for Milan, [16,5] for UCSF, and [0, 0-1] for other transplant variables, and [2-7,4-14] for explants variables except for tumor grade, [32,35]. ‡ p-values for comparison of LDLT and DDLT. Two-sample t-tests and chi-square tests were used for continuous variables and proportions, respectively. HCC=Hepatocellular carcinoma; LDLT=Living donor liver transplant; DDLT=Deceased donor liver transplant; LT=Liver transplant. Table 2. Characteristics of HCC patients at transplant (3/3) Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

14. A2ALL LDLTDDLT Tumor Stage on Explant Pre-MELDMELDAllPre-MELDMELDAllOverall T01/30/31/60/20/100/121/18 T10/30/40/70/20/90/110/18 T24/130/174/300/60/230/294/59 T36/17 12/340/55/175/2217/56 T4a3/103/66/160/41/131/177/33 T4b2/32/24/51/1 2/26/7 Missing0/11/11/20/10/30/41/6 Total16/50 (32%) 12/50 (24%) 28/100 (28%) 1/21 (5%) 7/76 (9%) 8/97 (8%) 36/197 (18%) Table 3. HCC recurrence post-LT by type of transplant, tumor stage on explant and MELD era Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

15. A2ALL HCC Recurrence onlyDeathHCC Recurrence or Death PredictorsHR95% CIp-valueHR95% CIp-valueHR95% CIp-value LDLT vs. DDLT2.35(1.04,5.35)0.04081.25(0.69,2.26)0.45721.51(0.88,2.59)0.1326 Number of HCC nodules in the liver 1.42(1.17,1.71)0.0003------ Diameter of largest nodule (cm) 1.27(1.13,1.42)<.00011.11(1.00,1.23)0.0611.14(1.04,1.26)0.0076 Vascular invasion1.96(0.94,4.11)0.07361.68(0.92,3.07)0.09181.97(1.13,3.44)0.017 AFP at Transplant (ng/mL, log) ---1.35(1.07,1.71)0.01261.29(1.02,1.63)0.0348 Table 4. Cox regression models predicting HCC recurrence, death, and the combined outcome post-transplant Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007 Panel A: for all HCC patients

16. A2ALL HCC Recurrence onlyDeathHCC Recurrence or Death PredictorsHR95% CIp-valueHR95% CIp-valueHR95% CIp-value LDLT vs. DDLT1.36(0.47,3.93)0.56870.85(0.33,2.19)0.74101.23(0.55,2.74)0.6094 Number of HCC nodules in the liver 1.7(1.30,2.22)0.0001------ Diameter of largest nodule (cm) 1.28(1.07,1.53)0.00661.19(1.03,1.38)0.01991.21(1.06,1.37)0.0036 Vascular invasion3.04(1.10,8.39)0.03143.45(1.43,8.34)0.00594.6(2.07,10.2)0.0002 AFP at Transplant (ng/mL, log) ---1.34(0.92,1.94)0.12741.14(0.80,1.64)0.4631 Table 4. Cox regression models predicting HCC recurrence, death, and the combined outcome post-transplant Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007 Panel B: for MELD era patients

17. A2ALL Figure 1. Cumulative probability over time of LDLT, DDLT, remaining alive on the waitlist, and death without transplant, from the first living donor evaluation (based on the cumulative incidence function) for (a) HCC patients in the Pre-MELD Era and (b) HCC patients in the MELD era. Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

18. A2ALL Figure 2: Probability of freedom from HCC recurrence by time since LDLT or DDLT for (a) all HCC patients (unadjusted), (b) HCC patients in the MELD era (unadjusted), and (c) all HCC patients (adjusted based on a Cox regression model, with both LDLT and DDLT groups presented for the overall average baseline characteristic values of two liver nodules, largest nodule 3.5 cm, and without vascular invasion) Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

19. A2ALL Figure 3. Unadjusted probability of patient survival by time since LDLT or DDLT for (a) all HCC patients and (b) HCC patients in the MELD era Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

20. A2ALL Figure 4. Unadjusted probability of recurrence-free survival by time since LDLT or DDLT for (a) all HCC patients and (b) HCC patients in the MELD era Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

21. A2ALL Figure 5. Adjusted probability of patient mortality by time from first living donor evaluation, for (a) all HCC patients and (b) HCC patients in the MELD era, both based on Cox regression models with both LDLT and DDLT groups presented for the average baseline characteristic values (55 years old, beyond Milan, AFP=10, lab MELD=12, and without ablation). Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

22. A2ALL Supplementary Table 1. Characteristics of the 126 MELD era HCC patients at donor evaluation (1/2) LDLT (n=50)DDLT (n=76) No Transplant (n=20) Characteristics † Mean ± SD or % p-value ‡ Mean ± SD or % Male gender76780.831465 Age (years) 56.7 ± 6.754.8 ± 8.1 0.1557 53.1 ± 11.9 Race 0.8234 White828675 African American225 Other161220 Etiology. % HCV+64740.259063 AFP (ng/mL) 0.0076 <20496661 20-40032 22 >40019317 Log AFP (ng/mL) 1.62 ± 1.041.13 ± 0.66 0.0052 1.59 ± 1.19 MELD12.4 ± 4.112.4 ± 4.30.976511.8 ± 4.8 Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

23. A2ALL Supplementary Table 1. Characteristics of the 126 MELD era HCC patients at donor evaluation (2/2) Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007 LDLT (n=50)DDLT (n=76)No Transplant (n=20) Characteristics † Mean ± SD or % p-value ‡ Mean ± SD or % Tumor stage0.0779 T0036 T14156 T2404850 T3382031 T417146 Beyond Milan55340.023438 Beyond UCSF40210.028314 Diameter of largest nodule (cm)4.7 ± 3.33.3 ± 1.80.01153.9 ± 2.9 HCC ablation before donor evaluation51730.0168 † Numbers of missing values for [LDLT, DDLT, no transplant] were [0,0,0] for gender, age, and race, [5,6,1] for HCV etiology of cirrhosis, [1-3,2-3,0-2] for AFP and MELD, and [1-3,10-13,4- 5] for the rest of the variables. ‡ p-values for comparison of LDLT and DDLT for age, log AFP, MELD, and diameter of largest nodule computed from t-test; and for all other characteristics from chi-square test.

24. A2ALL Supplementary Table 2. Characteristics of the 126 MELD era HCC transplanted patients at transplant (1/3) Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007 LDLT (n=50)DDLT (n=76) Characteristics† Mean ± SD or % p-value‡ At Transplant AFP (ng/mL)0.0385 <205162 20-4002834 >400215 Log AFP, ng/mL 1.6 ± 1.11.2 ± 0.7 0.0277 Donor Age, years 32.8 ± 9.143.2 ± 17.6 <0.0001 Cold Ischemia Time (minutes) 51.8 ± 38.2394 ± 197 <0.0001 MELD 13.3 ± 4.413.4 ± 6.0 0.9037 Beyond Milan43230.0281 Beyond UCSF33140.0195 HCC ablation from donor evaluation to LT22530.0005 Yes2253 No7846.1 HCC ablation ever60790.0213 No. of ablations since diagnosis 1.1 ±1.31.8 ± 1.5 0.0060 Days from donor Evaluation to LT68.9 ± 47.2149 ± 2060.0016

25. A2ALL Supplementary Table 2. Characteristics of the 126 MELD era HCC transplanted patients at transplant (2/3) Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007 LDLT (n=50)DDLT (n=76) Characteristics† Mean ± SD or % p-value‡ Explant Pathology Tumor stage0.4557 T0614 T1812 T23432 T33423 T41619 Beyond Milan50420.3526 Beyond UCSF41320.2914 Bilobar HCC43330.3175 Diameter of largest nodule (cm) 4.5 ± 2.93.5 ± 2.0 0.0410 No. of tumor nodules 2.3 ± 1.72.0 ± 1.7 0.3758 Vascular invasion26130.1009 Total Length of Nodules (cm)6.9 ± 4.65.4 ± 3.40.0565

26. A2ALL Supplementary Table 2. Characteristics of the 126 MELD era HCC transplanted patients at transplant (3/3) Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007 LDLT (n=50)DDLT (n=76) Characteristics† Mean ± SD or % p-value‡ Explant Pathology Tumor grade0.7609 G12123 G26456 G31521 † Numbers of missing values for [LDLT, DDLT] were [0-3,0-3] for transplant variables except for: AFP [11,11], donor age [0,10], and cold ischemia time [7,1]; and were [17,28] for grade and [0-3, 2-12] for all other explants variables. ‡ p-values for comparison of LDLT and DDLT. Two-sample t-tests and chi- square tests were used for continuous variables and proportions, respectively.

27. A2ALL Supplementary table 3a. Single-variable Cox models for HCC recurrence Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007 All HCC PatientsHCC Patients in the MELD Era Predictor Hazard Ratio 95% CIp-valueNGen. R 2 Hazard Ratio 95% CIp-valueNGen. R 2 LDLT vs DDLT3.76(1.71,8.26)0.0011976.50%2.97(1.17,7.54)0.02231264.26% Number of HCC Nodes in the liver1.35(1.15,1.59)0.00031946.11%1.56(1.25,1.95)0.000112410.69% Diameter of Largest Nodule (cm)1.27(1.15,1.41)<.00011769.26%1.26(1.11,1.43)0.00031119.04% Vascular Invasion2.76(1.38,5.54)0.00421843.80%4.53(1.79,11.42)0.00141147.48% Years from Donor Evaluation to Transplant0.23(0.05,1.15)0.0731972.70%0.33(0.04,2.50)0.28231261.25% Grade 3 vs. Non-Grade 34.16(1.93,8.98)0.00031308.34%3.41(1.21,9.60)0.02815.70% Ever Had an Ablation0.62(0.32,1.19)0.15181971.01%0.43(0.17,1.05)0.06361262.58% Etiology of Cirrhosis at Txp1.56(0.81,3.00)0.18551960.88%1.45(0.55,3.84)0.45321250.43% MELD at Transplant (max 40)0.96(0.90,1.04)0.32371950.52%0.96(0.86,1.06)0.40611250.58% Recipient Age at Txp (per 10 yrs)0.99(0.67,1.44)0.9381970.00%1.18(0.67,2.08)0.55551260.28% Donor Age at Txp (per 10 yrs)1.05(0.83,1.32)0.70521720.08%1.14(0.84,1.53)0.39791160.61% Cold Ischemia Time (hrs)0.87(0.77,0.98)0.02641713.29%0.84(0.73,0.98)0.0291184.66% Milan Stage at Explant6.36(2.47,16.41)0.000119110.53%57.0*(3.14-1030)*<0.000112223.70% UCSF Stage at Explant5.44(2.47,11.98)<.000119110.81%11.9(3.44,41.24)<.000112316.55% Log AFP at Transplant1.64(1.21,2.22)0.00141715.14%1.61(1.03,2.53)0.03741043.68% AFP>20 at Txp1.62(0.83,3.15)0.15561711.18%2.42(0.98,5.97)0.05431262.85% *Based on Firth estimate in the presence of separation

28. A2ALL Supplementary table 3b. Single-variable Cox models for death Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007 All HCC PatientsHCC Patients in the MELD Era Predictor Hazard Ratio 95% CIp-valueNGen. R 2 Hazard Ratio 95% CIp-valueNGen. R 2 LDLT vs DDLT1.32(0.80,2.16)0.27621970.61%1.28(0.62,2.65)0.49841260.36% Number of HCC Nodes in the liver1.09(0.96,1.24)0.18581940.86%1.28(1.06,1.53)0.00851244.98% Diameter of Largest Nodule (cm)1.12(1.02,1.23)0.02281762.56%1.14(1.01,1.27)0.02991113.58% Vascular Invasion1.86(1.06,3.24)0.02931842.30%3.36(1.57,7.20)0.00181147.19% Years from Donor Evaluation to Transplant1.41(1.00,1.98)0.04671971.53%2.45(1.32,4.55)0.00451264.66% Grade 3 vs. Non-Grade 31.83(0.93,3.60)0.07981302.09%1.82(0.72,4.61)0.2076811.75% Ever Had an Ablation0.8(0.49,1.32)0.38541970.38%0.52(0.25,1.07)0.07641262.35% Etiology of Cirrhosis at Txp1.44(0.88,2.37)0.14651961.06%0.64(0.25,1.61)0.34171250.78% MELD at Transplant (max 40)1.06(1.02,1.11)0.00631953.41%1.07(1.00,1.15)0.05681252.64% Recipient Age at Txp (per 10 yrs)1.07(0.81,1.42)0.63371970.12%1.13(0.73,1.76)0.57741260.25% Donor Age at Txp (per 10 yrs)1.06(0.88,1.29)0.52781720.23%1.11(0.87,1.42)0.41211160.57% Cold Ischemia Time (hrs)0.96(0.89,1.04)0.34891710.53%0.88(0.78,0.99)0.02851184.41% Milan Stage at Explant1.44(0.87,2.39)0.15791911.06%2.87(1.29,6.36)0.00951225.81% UCSF Stage at Explant1.92(1.16,3.16)0.01061913.40%3.15(1.47,6.73)0.00311237.05% Log AFP at Transplant1.42(1.13,1.79)0.00261714.68%1.45(0.99,2.11)0.05491043.20% AFP>20 at Txp2.03(1.20,3.43)0.00811714.15%2.11(1.03,4.33)0.04111263.19%

29. A2ALL Supplementary Figure 1. Characteristics of HCC patients among those who had LDLT and recurred within one year post-transplant, all other LDLTs, and DDLTs. Tumor grade was available for 11 (79%), 57(66%), and 62(64%), in the 3 respective groups. Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

30. A2ALL Results Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007 HCC recurrence: –Among entire cohort, Unadjusted probability of HCC recurrence was higher in LDLT (38%) than in DDLT (11%) (p = 0.0004). Adjusted for tumor characteristics, HCC recurrence remained higher in LDLT (HR = 2.35, 95% CI 1.04-5.35; p = 0.04). –In the MELD era, LDLT was not significantly associated with HCC recurrence after adjusted for tumor characteristics (HR = 1.36, 95% CI 0.47-3.93; p = 0.57) Overall survival and recurrence-free survival were not significantly different in LDLT compared to DDLT for the entire cohort as well as the MELD era patients Sequential stratification from time of enrollment did not show a significant survival benefit associated with LDLT who received LDLT likely played a role in the higher HCC recurrence rate

31. A2ALL Results Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007 Predictors of HCC recurrence: –Among entire cohort, LDLT, greater size of largest nodule, and larger number of nodules were associated with higher HCC recurrence. –In the MELD era, LDLT, greater size of largest nodule, larger number of nodules, and vascular invasion were associated with higher HCC recurrence. Predictors of mortality: –Among entire cohort, higher AFP at transplant was associated with higher mortality. –In the MELD era, greater size of largest nodule and vascular invasion were associated with higher mortality. Predictors of recurrence-free survival: –Among entire cohort, greater size of largest nodule, larger number of nodules, and higher AFP at transplant were associated with higher mortality. –In the MELD era, greater size of largest nodule and vascular invasion were associated with higher mortality.

32. A2ALL Conclusions Differences in tumor characteristics and management of HCC in patients who received LDLT likely played a role in the higher HCC recurrence rate observed in LDLT. in patients who received LDLT likely played a role in the higher HCC recurrence rate Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007

33. A2ALL Limitations Non randomized; differences in tumor characteristics between LDLT and DDLT Lack of uniformity in treatment for HCC prior to transplant Prioritization for MELD changed during the study period Kulik, L. M. et al. Am J Transplant. 2012 Nov;12(11):2997-3007