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  • Title: Liver transplantation and waitlist mortality for HCC and non-HCC candidates following the 2015 HCC exception policy change.
    Author: Ishaque T, Massie AB, Bowring MG, Haugen CE, Ruck JM, Halpern SE, Waldram MM, Henderson ML, Garonzik Wang JM, Cameron AM, Philosophe B, Ottmann S, Rositch AF, Segev DL.
    Journal: Am J Transplant; 2019 Feb; 19(2):564-572. PubMed ID: 30312530.
    Abstract:
    Historically, exception points for hepatocellular carcinoma (HCC) led to higher transplant rates and lower waitlist mortality for HCC candidates compared to non-HCC candidates. As of October 2015, HCC candidates must wait 6 months after initial application to obtain exception points; the impact of this policy remains unstudied. Using 2013-2017 SRTR data, we identified 39  350 adult, first-time, active waitlist candidates and compared deceased donor liver transplant (DDLT) rates and waitlist mortality/dropout for HCC versus non-HCC candidates before (October 8, 2013-October 7, 2015, prepolicy) and after (October 8, 2015-October 7, 2017, postpolicy) the policy change using Cox and competing risks regression, respectively. Compared to non-HCC candidates with the same calculated MELD, HCC candidates had a 3.6-fold higher rate of DDLT prepolicy (aHR = 3.49 3.69 3.89 ) and a 2.2-fold higher rate of DDLT postpolicy (aHR = 2.09 2.21 2.34 ). Compared to non-HCC candidates with the same allocation priority, HCC candidates had a 37% lower risk of waitlist mortality/dropout prepolicy (asHR = 0.54 0.63 0.73 ) and a comparable risk of mortality/dropout postpolicy (asHR = 0.81 0.95 1.11 ). Following the policy change, the DDLT advantage for HCC candidates remained, albeit dramatically attenuated, without any substantial increase in waitlist mortality/dropout. In the context of sickest-first liver allocation, the revised policy seems to have established allocation equity for HCC and non-HCC candidates.
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