Abstract

Background:

Recently, UNOS implemented the median MELD score at transplant minus 3 points (MMaT-3) policy for patients with hepatocellular carcinoma (HCC) granted exception points to reduce the disparity in access to liver transplant (LT). Preliminary data suggests improved geographic disparity between HCC and non-HCC patients, but lower LT probability and longer wait time was observed in HCC patients in regions with previously quicker access to LT. We aimed to evaluate the effect of this policy on post-LT outcomes.

Methods:

Using the UNOS registry, we compared post-transplant outcomes in HCC patients who received LT in the pre-MMaT era (8/15/17-11/15/18) and MMaT era(6/1/19-8/30/20). We compared patient survival and HCC recurrence rates among HCC patients in both eras with follow-up time until December 31, 2021. HCC recurrence was defined as death due to HCC, reported recurrence by center, or poorly differentiated pathology on explant. Cox Hazard regression analysis was performed to determine risk for post-LT mortality and logistic regression was performed for HCC recurrence between groups.

Results: 1899 (56.0%) HCC patients received LT in the pre-MMaT era, and 1491 (44.0%) in the MMaT era. 1 year post-LT survival rates were 0.94 (95% CI: 0.93-0.95) and 0.92 (95% CI: 0.90- 0.93) in the pre-MMaT and MMaT eras. 1-year post-transplant mortality adjusted for age, gender, and race/ethnicity was 35% higher in MMaT era (aHR 1.35 95% CI 1.02-1.78 ). Similarly, we found that HCC patients in the MMaT era had a 70% higher likelihood of recurrence (1.70 OR 95% CI 1.33 -2.17). Poorly differentiated HCC at explant was also found to increase by 3 folds (sHR 2.92, 95% 1.58–5.4) after the policy change.

Conclusion: Post-LT outcomes including survival and recurrence rates for HCC patients were significantly worse in the MMaT era. Further studies are needed to determine potential determinants contributing to these changes and the impact on long-term outcomes.