American Journal of Transplantation 2010; 10: 18341841 Wiley Periodicals Inc.

C 2010 The Authors Journal compilation C 2010 The American Society of Transplantation and the American Society of Transplant Surgeons

doi: 10.1111/j.1600-6143.2010.03088.x

Clinical Outcomes for Saudi and Egyptian Patients Receiving Deceased Donor Liver Transplantation in China
N. Allama , M. Al Saghierc , Y. El Sheikhc , M. Al Sofayanc , H. Khalafc , M. Al Sebayelc , A. Helmyc , Y. Kamelc , A. Al Jedaid , H. Abdel-Dayemb , N. M. Kenetmane , A. Al Saghierf , W. Al Hamoudif and A. A. Abdof, *
a Departments of Hepatology and b Surgery, National Liver Institute, Menofeya University, Egypt c Departments of Liver Transplantation and d Pharmacy, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia e Section of Hepatobiliary, Pancreatic, and Transplant Surgery, University of Alberta, Edmonton, Canada f Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia *Corresponding author: Ayman Abdo, aabdo@ksu.edu.sa

Abbreviations: ARDS, adult respiratory distress syndrome; CMV, cytomegalovirus; DDLT, deceased-donor liver transplantation; EBV, EbsteinBarr virus; GVHD, graft-versus-host disease; HAT, hepatic artery thrombosis; HBV, Hepatitis B virus; HCV, Hepatitis C; HCC, hepatocellular carcinoma; KFSH&RC, King Faisal Specialist Hospital & Research Centre; KSA, Kingdom of Saudi Arabia; LDLT, living-donor liver transplantation; MELD, model of end-stage liver disease; PCR, polymerase chain reaction PGNF, primary graft nonfunction; PVT, portal vein thrombosis; SIRS, systemic inammatory response syndrome; UCSF, University of California San Francisco. Received 02 July 2009, revised 23 January 2010 and accepted for publication 25 January 2010

Long waiting list times in liver transplant programs in Saudi Arabia and unavailability of deceased donor transplantation in Egypt have led several patients to seek transplantation in China. All patients who received transplants in China and followed in three centers from January 2003January 2007 were included. All patients charts were reviewed. Mortality and morbidity were compared to those transplanted in King Faisal Specialist Hospital & Research Centre (KFSH&RC) during the same period. Seventy-four adult patients were included (46 Saudi nationals; 28 Egyptians). One-year and 3-year cumulative patient survival rates were 83% and 62%, respectively compared to 92% and 84% in KFSH&RC. One-year and 3-year cumulative graft survival rates were 81% and 59%, respectively compared to 90% and 84% in KFSH&RC. Compared to KFSH&RC, the incidence of complications was significantly higher especially biliary complications, sepsis, metastasis and acquired HBV infection posttransplant. Requirements of postoperative interventions and hospital admissions were also signicantly greater. Our data show high mortality and morbidity rates in Saudi and Egyptian patients receiving transplants in China. This could be related to more liberal selection criteria, use of donation after cardiac death (DCD) donors or possibly more limited posttransplant care. Key words: Biliary complications, China, deceased donor grafts, non-heart beating, outcome, transplant hepatology

Introduction
Liver transplantation is the only effective and available therapy for patients with end-stage liver disease. Many advances in the eld, such as rened surgical techniques, improved intensive care, more targeted immunosuppressive agents, improved organ procurement techniques and better preservation solutions, have led to excellent shortterm and long-term clinical outcomes, yielding patient survival rates of approximately 85% and 75% 1 year and 5 years after transplantation, respectively (1). In spite of great advances in deceased and living-related liver transplantation in Kingdom of Saudi Arabia (KSA) (2) and the establishment of living-related transplantation in Egypt (3), the international problem of organ shortage is much more pronounced in KSA and Egypt owing to the high prevalence of hepatitis B and C that leads to a huge demand for liver transplantation, reected by the thousands of referrals made annually to transplant centers. Despite this, only approximately 60 liver transplantations are performed annually across all centers in KSA (4). As a result of this distressing mismatch between need and organ availability, an increasing number of Saudi patients seek liver transplantation abroad. In Egypt, the situation is even more difcult because transplants can only be performed from living donors. A combination of many factors including easy accessibility, relatively low cost, relatively short waiting time and

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more liberal transplantation indications, has led a growing number of Saudi and Egyptian patients to seek liver transplantation in China. In fact, patients from all over the world, including Southeast Asia, North America, Europe and Australia, have begun to travel to China for organ transplantation. It is commonly said that liver transplantation in China is quite affordable, with reference to the high cost of treatment in the USA and Europe. It is also possible to procure an organ in a relatively short time (5). Despite these attractive factors, the main growing concern with this choice is the uncertainty regarding the outcome. Therefore, we describe, in this retrospective study, the clinical outcomes for patients who obtained liver transplants in China and were subsequently followed in our centers, and present our experience in managing their care, with special emphasis on patient and graft survival as well as the rates of complications.

Methods
Patients who received deceased-donor liver transplantation (DDLT) in China between January 2003 and January 2007 and were followed posttransplantation in King Faisal Specialist Hospital & Research Centre (KFSH&RC) and Al-Salama and Mahmoud Hospitals were included in this study. This group does not represent all Saudi and Egyptian patients who received transplantation in this period but only the ones followed in our centers. These patients transplanted in China were compared to patients transplanted in KFSH&RC in the same period. Patients transplanted in KFSH&RC had been referred from different hospitals in the Kingdom. They were assessed by the transplant team, listed and prioritized according to the Model of endstage liver disease (MELD) score. All their clinical and laboratory data were documented in charts and on the hospital computer information system. Their operative details and postoperative follow-up at the hospital was also documented. Medical records of both groups were reviewed for the following relevant data. Data sources included paper charts, discharge summaries, operative reports, computerized laboratory databases and our institutions electronic transplant medical record.

and hepatic vein thrombosis were diagnosed by Doppler ultrasonography, CT scanning and/or angiography (6). Biliary complications included leaks and strictures. The presence of a bile leak was identied when intraabdominal uid accumulation was revealed by imaging (ultrasound or CT) and was conrmed by aspiration and/or pig-tail drainage or at the time of reexploration. A stricture was dened as a symptomatic (e.g. cholangitis, hyperbilirubinemia) narrowing in the biliary tree identied either by magnetic resonance cholangiopancreatography, percutaneous transhepatic cholangiogram (PTC) or endoscopic retrograde cholangiogram (ERCP) (7). Sepsis referred to systemic inammatory response syndrome (SIRS) when there was a conrmed infectious origin. The diagnosis of SIRS was based on the American College of Chest Physicians and the Society of Critical Care Medicine criteria (8). Opportunistic infections: Only symptomatic Cytomegalovirus (CMV) and EbsteinBarr virus (EBV) infections were collected. EBV infection was dened as the occurrence of severe malasie, fever, u-like symptoms (infectious mononucleosis) or elevated liver function tests, splenomegaly and lymphadenopathy associated with lab markers (viral capsid antigen or EBV nuclear antigen, PCR for EBV DNA) (9). The denitive diagnosis of PTLD relied on histopathologic examination of biopsy specimens. CMV disease was dened as the presence of fever, malaise, leukopenia, atypical lymphocytosis or thrombocytopenia in conjunction with a positive CMV antigenemia assay (pp 65) (10). Tissue-invasive CMV was dened as organ dysfunction not attributable to rejection in conjunction with evidence of CMV in a biopsy specimen of the affected organ (10).

Comparisons regarding the survival rate and morbidity were made between the two groups of patients. No patients were included from the Egyptian Centre as there is no DDLT program in Egypt till now. The study was approved by the Institutional Review Board in all three centers.

Statistical Analysis
Data were collected in a specialized Data Collection Form then entered in the Statistical Package for Social Sciences (SPSS, version 15.0; SPSS Inc., Chicago, IL) for windows. Data are expressed as median and range, and frequencies as appropriate. Chi-square tests and Fishers exact tests were used to compare the frequency of complications in the different groups. Using the software SAS version 9.2, a KaplanMeier analysis was done to measure the patient and graft survival function, and the log-rank test was used to compare survival rates. A p-value of < 0.05 was considered statistically signicant.

1. Pretransplant data: details of patient demographics, disease indications, MELD score, and duration between contacting the Chinese hospital and traveling to China. 2. Reports from China: comments on the duration of hospital stay before transplantation, postoperative management including immunosuppressive regimens, early postoperative complications (vascular, biliary, infectious etc.), if any, and the duration of postoperative stay in China. 3. Follow-up after return from China: Patients were followed up regularly in the KFSH outpatient clinic. Routine laboratory investigations, abdominal computed tomography (CT) scans and Doppler ultrasonography were performed routinely upon a patients arrival for posttransplant survey, and the image studies were repeated when clinically indicated. Types of complications and survival status of patients and grafts were retrospectively reviewed. Special attention was given to recording the following complications.

Results
I. Pretransplant data The China Group included 74 patients who underwent DDLT in China. The age of the patients ranged from 31 to 71 years, the median was 54, and 13(17.6%) patients were above the age of 65 years. Sixty (81.1%) were males, and 14 (18.9%) were females. Forty-six (62.2%) patients were Saudi nationals and 28 (37.8%) were Egyptians (Table 1).
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Vascular complications, namely portal vein thrombosis (PVT), portal vein stenosis, hepatic artery stenosis, hepatic artery thrombosis (HAT)

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Table 1: Baseline characteristics for patients receiving transplantation in China and King Faisal Specialist Hospital & Research Centre (KFSH&RC) Variable Age: (range, median) (years) Gender: (Male/female) n Median MELD score Selection: HCC exceeding Milan criteria Etiology of underlying liver disease: n (%) HCV-related decompensated cirrhosis HCC HBV-related decompensated cirrhosis Autoimmune hepatitis Cryptogenic cirrhosis Metabolic liver disease Others China (n = 74) 3171; 54 60/14 17 5 (6.76) China n (%) 29 (39.18) 24 (32.5) 13 (17.56) 2 (2.7) 3 KFSH&RC (n = 120) 1664; 45 74/46 19 KFSH&RC n (%) 38 (31.68) 21 (17.5) 14 (11.7) 17 (14.2) 10 (8.3) 7 (5.8) 13 (10.8) p-Value <0.01 <0.05 >0.05 <0.001 <0.05

HCV = hepatitis C virus; HBV = hepatitis B virus; HCC = heptocellular carcinoma; N= number; MELD = model of end-stage liver disease.

The indications for liver transplantation were decompensated cirrhosis due to hepatitis C (n = 29); hepatocellular carcinoma (HCC n = 24); hepatitis B (n = 13); others (n = 8). The median MELD score (at the time of travel to China) was 17 (Table 1). (Median MELD for HCC cases was 14; for non-HCC 19). Only 5 (6.8%) patients had a MELD score of 25. All patients transplanted in China were either on the KFSH&RC waiting list for liver transplantation (n = 33) or had been denied liver transplantation at the KFSH&RC or in Egypt (n = 41). Reasons for rejection of transplantation were unsuitable medical condition due to multiple comorbidities (n = 23), age above 65 (n = 13), or advanced hepatocellular carcinoma (tumors exceeding Milan and UCSF criteria) (n = 5). In comparison, the 120 patients transplanted at KFSH&RC were younger (median 45 years) and the ratio of males to females was less (61.6%: 38.4%). Indications for liver transplantation were also mostly viral-related decompensated cirrhosis (HCV 38 cases; HBV 13) and HCC (n = 21) followed by autoimmune hepatitis (n = 17); cryptogenic cirrhosis (n = 10); metabolic liver disease (n = 7), and a few other causes (n = 13). The median MELD score in the KFSH&RC group at the time of transplant was 19 (not signicantly different from that of the other cohort) (Table 1). Median MELD for patients with HCC was 14 and for the non-HCC was 20. Regarding the average waiting time in KFSH&RC, it ranged from 1 to 1164 days with a median of 15 weeks.

stay in China ranged from 10 to 70 days, with a median of 50 days (Table 2).

Donors data: Donor age data for the China cohort was recorded (range 2035 years, median 25 years) compared to a median deceased donor age of 34 years (861) in the KFSH&RC patients. Cause of death in the China cohort donors was recorded as severe brain injury in all cases according to the reports provided. Further details of sources of these donors cannot be conrmed. Operative details: Data regarding the operative details and the pathology of the explanted liver were usually missing or incomplete. Postoperative immunosuppression regimens: Almost all the transplant recipients were given triple therapy of methylprednisolone, tacrolimus and mycophenolate mofetil. In two patients only, cyclosporine was used in place of tacrolimus. Mortality: Two patients died in China very early after surgery due to unknown cause.
Table 2: Transplant center location for patients transplanted in China Location: n (%) - Tianjin - Xiangya - Sun Yat-Sen - Shanghai - Hangzhou - Beiging - Pla Period between contacting Chinese hospitals and travel (range/median) In-China waiting period (range/median) Duration of posttransplant stay (range/median) 58 (78.38) 4 (5.42) 1 (1.35) 4 (5.4) 4 (5.4) 2 (2.7) 1 (1.35) 216 weeks/4 weeks.

II. Reports from China Transplant sites: Fifty-eight patients were given transplants at Tianjin, 4 in Shanghai, 4 in Hangzhou, 4 in Xiangya, 2 in Beijing, 1 in each of Sun Yat-Sen and Pla (Table 2). In-China waiting period and stay: The waiting time in China prior to receiving liver transplant ranged from 5 to 20 days, with a median of 14 days. The duration of posttransplant
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520 days/14 days. 1070 days/50 days.

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Table 3: Comparison between posttransplant complications for patients transplanted in China and KFSH&RC Complication Biliary complications Diffuse biliary stricture Anastomotic stricture Bile leakage Vascular complications Portal vein thrombosis Portal vein stenosis Hepatic artery thrombosis Recurrent HCC Sepsis Acquired HBV infection Opportunistic infections (CMV/EBV) China (n = 74) 24 (32.4) 14 6 4 4 (5.4) 2 1 1 3 (4) 7 (9.5) 4 (5.4) 2/0 (2.7) KFSH&RC (n = 120) 14 (11.7) 5 2 7 7 (5.8) 2 1 3 3 (2.5) 1 (0.83) 0 (0) 1/1 (1.7) p-Value <0.01

>0.05

>0.05 <0.01 <0.05 >0.05

III. Follow-up Patients who were transplanted in China were then followed in our centers. We present their data till closure of the study in January 2008. During this period, patients had received follow-up care for a median of 13 months (range 260 months).
In comparison, the median follow-up for the KFSH&RC group (who were also followed till January 2008) was 28 months (range 1 week60 months). All transplant recipients were started on triple therapy consisting of prednisone, calcineurin inhibitor (mostly tacrolimus) and mycophenolate mofetil. Tacrolimus level target is 10 12 ng/mL in the rst 3 months then 810 ng/mL thereafter. Steroids were then tapered over the rst 3 months. Most patients were off steroids by the fourth month and left on calcineurin inhibitor alone. Mycophenolate mofetil was stopped by the end of 3 months posttransplant if no rejection occurred within rst 3 months or in nonautoimmune patients. Calcineurin inhibitors levels were measured in every visit.

tients suffered from orid cytomegalovirus infection: one from severe pneumonitis 1 month after transplant and the other from encephalitis. Both were diagnosed clinically, by CMV antigenemia and PCR. The patient with severe pneumonitis was from the beyond-Milan criteria HCC group. HCC recurred in three patients within the rst year. All patients were beyond Milan criteria and had been denied transplant in their home country. Median time to tumor recurrence was 6 months. Sites of tumor recurrence were liver, lung, bone and brain. Regarding the 13 patients who were initially rejected from KFSH&RC because of age above 65 and subsequently transplanted in China, two had portal vein thrombosis, one had biliary stricture, ve required repeated admissions to the hospital during the rst year, and three suffered from severe infections. When the China cohort was compared to the KFSH&RC cohort, the incidence of particular complications was signicantly higher. This was especially true for biliary complications (p 0.01), sepsis [whether due to cholangitis or infections elsewhere] (p 0.01), and acquired HBV infection posttransplant (p 0.05). It was thus noted that patients who were transplanted in China had a signicantly higher need for postoperative interventions whether ERCP , PTC or pigtail drainage. Eighteen patients (24%) required a total of 41 interventions while 7 (5.8%) of the KFSH&RC cohort required a total of 8 interventions (p 0.05). These procedures necessitated frequent hospital admissions, visits to the day medical unit, visits to the emergency room and laboratory investigations, thus placing a heavier burden on the resources of the hospital. For those with complications, the calculated average hospital stay in the rst year was 48 days. In addition, 40 (60%) of the China cohort patients presented to the ER more than once per year compared to 52 (43%) of the KFSH cohort (p < 0.05%).
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Complications in both groups in the follow-up period A comparison of the more frequently encountered complications in both groups is presented in Table 3. Many of the patients transplanted in China suffered from multiple morbidities. Overall, biliary complications were the most common. This included 14 patients with diffuse strictures requiring repeated ERCP and PTC, necessitating surgery in two patients and culminating in retransplantation in one patient. Six patients suffered from anastomotic strictures, and four from bile leaks requiring pig tail drainage. Biliary tract infection-related septicemia was observed in ve patients.
Three patients suffered from symptomatic abdominal collections conrmed on imaging, two of whom required repeat laparotomy for drainage. It is worth to note that four patients acquired hepatitis B infection. Regarding severe opportunistic infections, two paAmerican Journal of Transplantation 2010; 10: 18341841

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Table 4: Mortality data for patients transplanted in China and KFSH&RC Mortality (n) Causes of death Vascular complications PGNF Biliary complications Recurrent malignancy Severe infections Chronic rejection and end-stage renal disease Fibrosing cholestatic hepatitis Decompensated cirrhosis due to recurrent HCV Central pontine myelinolysis GVHD Myocardial infarction Unknown cause China (18/74) n (%) 1(5.55%) UNK 9 (50) 3 (16.7) 1 (5.55) 0 1 (5.55) 0 0 1 (5.55) 0 2 (11.1) KFSH&RC (16/120) n (%) 3 (18.75) 2 (12.5) 2 (12.5) 2 (12.5) 1 (6.25) 1 (6.25) 0 2 (12.5) 1 (6.25) 1 (6.25) 1 (6.25) 0

median survival time of the China group (1287 days) was signicantly less than that of the KFSH&RC (1582 days) (p 0.01). One-year and 3-year cumulative patient survival rates for the China patients were 83% and 62%, respectively, compared to 92% and 84% for the KFSH&RC cohort (p 0.01) (Figure 1). Similarly, 1-year and 3-year cumulative graft survival rates for the China group were 81% and 59%, respectively, and 90% and 84% for the KFSH&RC group (p 0.01) (Figure 2).

Discussion
The current organ shortage crisis in KSA, the absence of a DDLT program in Egypt and the high prevalence of chronic liver diseases in both countries have led to a consequent increase in the number of patients from both countries seeking transplantation abroad, especially in China. China has made great strides in liver transplantation in recent years. However, unlike their Asian counterparts who have relied on living donor liver transplantation, deceased donors account for more than 95% of allografts for liver transplantation in China (11). The Chinese procedure also has the advantages of being very accessible and relatively inexpensive as compared to Western centers (12). The exact number of Saudi and Egyptian patients who travel to China for liver transplantation is not known, but it seems that this number is steadily rising. However, limited reports suggest that foreign nationals traveling to China to receive liver transplantation may not have the same results as those receiving livers in their home countries. This may be due to less restrictive indications for transplantation, high posttransplant complications and mortality rates and possibly more limited posttransplant care. The clinical outcomes of the 74 patients reported in this study were inferior compared to outcomes of patients transplanted at KFSH&RC. The mortality and morbidity rates were signicantly higher and about half of the patients sustained complications. The most common complications seen in these patients were biliary in nature, mainly diffuse biliary strictures. In general, diffuse strictures occur as a result of ischemia from hepatic artery thrombosis, extended graft preservation, or long warm ischemia times. Data regarding the process of donor liver graft preservation as well as the length of cold and warm ischemia times in our patients transplanted in China were not available in their accompanying reports. However, it is likely that these diffuse strictures were caused by warm ischemic injury to the donor liver during procurement, since the hepatic arteries of almost all of these patients were patent according to Doppler ultrasound. In fact, the patients who received transplants in China did not exhibit a higher incidence of vascular complications than the KFSH&RC group. Similar to the present study, Wong et al. reported that up to 53% of patients from Hong Kong who underwent transplantation
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China cohort: 18 patients died out of 74. KFSH cohort: 16 patients died out of 120. Mortalities are expressed as number and percentage of the total number of mortalities. UNK = Unknown.

Mortality in both groups Eighteen (24.3%) patients died after receiving transplantation in China; two died in the Chinese centers very early after surgery due to unknown cause. After the return from China, another 16 patients died during follow-up in KFSH&RC. The causes of death are shown in Table 4: complications related to biliary stricture (n = 9); severe pneumonia due to CMV (n = 1) and Graft-versus-host disease (GVHD) (n = 1); poor graft function due to PVT (n = 1); brosing cholestatic hepatitis C (n = 1) and recurrent HCC (n = 3).
It is worth noting that the eight patients who died in the rst year posttransplant had been initially denied transplantation in their home country because of older age (8/13 = 61.5%). On the other hand, 16 of the KFSH&RC patients (13.3%) died during follow-up. Three patients died in the rst week due to: hemorrhage (n = 1) and primary graft nonfunction (n = 2). One died after 3 weeks of HAT. Other causes of death are summarized in Table 4 and included: biliary complications (n = 2); myocardial infarction (n = 1); sepsis and ARDS (n = 1); recurrent malignancy: HCC, cholangiocarcinoma (n = 2); chronic rejection and end-stage renal disease (n = 1); GVHD (n = 1); poor graft function due to PVT (n = 1); central pontine myelinolysis (n = 1); and recurrent HCV leading to decompensated cirrhosis (n = 2). When comparing patients who were transplanted in China with those transplanted in KFSH&RC in terms of mortality,
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Figure 1: KaplanMeier curve of the cumulative patient survival in patients transplanted in China and in King Faisal Specialist Hospital & Research Centre.

in mainland China experienced diffuse biliary complications that involved both intra- and extrahepatic biliary systems (5). This pattern is similar to the complications associated with procurement without heparinization or when uncontrolled, non-heart-beating donors are involved (1320). Lee Poh-hsing, from the National Taiwan University Hospital, reasoned that the discrepancy between the 1-year survival rates of patients who are treated in Taiwan (85%) and those of the hundreds of Taiwanese who go to China every year for liver transplantations (50%) was likely due to suboptimal procurement of organs (21).

Differences in outcome between China and KFSH&RC groups may also be attributed to differences in patients selection criteria as Chinese centers accepted candidates who were rejected locally because of older age and HCC beyond Milan and UCSF criteria. In our study, as shown in Table 1, the mean age of the patients obtaining transplants in China was signicantly higher, than that of the locally transplanted patients. An additional complication that occurred in four of the patients who were transplanted in China (compared to none

Figure 2: KaplanMeier curve of the cumulative graft survival in patients transplanted in China and in King Faisal Specialist Hospital & Research Centre.

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in KFSH) was the development of de novo hepatitis B. According to accompanying reports, none of these patients received standard protective measures such as hepatitis B immunoglobulin or antiviral therapy and none were informed of their HBV status. All of these patients were HBsAg negative before they left for China. All four patients were put on antiviral therapy on return to their home country and continued to have normal graft function. As a consequence of the complications described above, many patients who went to China for transplantation and were followed afterward in our centers required repeated hospital admissions, frequent visits to the Emergency Department, more laboratory investigations and repeated diagnostic and therapeutic interventions including ERCP , PTC, liver biopsy and laparotomy, resulting in a signicant effect on the patients quality of life and a signicant additional, nancial and resource burdens on the local transplant programs. Moreover, both graft and patients survival were affected and shortened compared to locally transplanted patients. It is difcult to access data describing transplantation outcomes in Chinese centers, since there is a very limited literature published in English. In addition, the indications, listing process, waiting time, retrieval process and long-term outcomes are unclear. In one of the rare publications from China, Zhongyang et al. reported that in Tianjin First Central Hospital (where 58 of the present cohort received their transplants), 1510 adult liver transplants were performed between January 2000 and June 2005, all from deceased donors, including 1430 primary transplantations and 80 retransplantations. One hundred seventeen (7.74%) recipients died in the perioperative period (ICU stay). Four patients died of pulmonary embolism during the operation. Overall, the 1-year survival rate was 87.36% (22). Sun YatSen Medical University (one of the centers discussed in the present study) reported the performance of 70 liver transplants with a short-term survival rate of 77% with 54 patients surviving for more than 1 month and 16 patients dying within 30 days after transplantation. The operative mortality rate was 18.6% in this group, which was signicantly lower than that of the historical group in China (23). In another study by Wu et al. no perioperative death occurred, and 1- and 2-year cumulative survival rates were 90.0% and 65.6% (24). We would like to emphasize that the results presented in this study regarding the outcome of the patients who underwent liver transplantation in China may not represent the actual survival data of the Chinese centers, and is not a head-to-head comparison with the outcome at KFSH&RC. Indeed, the presented data from China are only of the patients who are followed up in our center, and do not include those who may have had early death or complications, those who are followed elsewhere, and all other non-Saudi and non-Egyptian patients not known to us.
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In conclusion, our data suggest that mortality and morbidity rates for Saudi and Egyptian patients receiving transplants in China are higher than for patients receiving liver transplants at home. This is likely due to more liberal selection criteria and the use of DCD donors in China. Clinicians considering referral of patients to China for DDLT should be aware of the potential risks their patients may encounter and the associated cost impact on medical resources utilization. Patients should also be enlightened about these risks.

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