• Tanveen Ishaque, Allan B Massie, Mary G Bowring, Christine E Haugen, Jessica M Ruck, Samantha E Halpern, Madeleine M Waldram, Macey L Henderson, Jacqueline M Garonzik Wang, Andrew M Cameron, Benjamin Philosophe, Shane Ottmann, Anne F Rositch, and Dorry L Segev.
• Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
• Am. J. Transplant. 2019 Feb 1; 19 (2): 564-572.

AbstractHistorically, 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.© 2018 The American Society of Transplantation and the American Society of Transplant Surgeons.

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