Liver transplantation and waitlist mortality for HCC and non-HCC candidates following the 2015 HCC exception policy change

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, Dorry L Segev, 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, Dorry L Segev

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.

Keywords: cancer/malignancy/neoplasia; clinical research/practice; disparities; graft survival; liver disease: malignant; liver transplantation/hepatology; organ allocation.

Conflict of interest statement

DISCLOSURE

The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

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

Figures

Figure 1.
Figure 1.
Construction of the study population.
Figure 2.
Figure 2.
Cumulative incidence of DDLT for HCC (solid) and non-HCC (dash) candidates. Pre-policy (blue), DDLT was substantially higher for HCC candidates than for non-HCC candidates at 24 months post-study entry (88.4% vs. 46.3%). Post-policy (red), DDLT was lower for HCC candidates until 6 months post-study entry (14.1% vs. 44.1%), started to increase sharply at 6 months post-study entry, and became higher than non-HCC candidates (90.6% vs. 57.2% after 24-month).
Figure 3.
Figure 3.
Cumulative incidence of (a) waitlist mortality/dropout, (b) waitlist dropout (c) waitlist mortality for HCC (solid) and non-HCC (dash) candidates in pre-policy (blue) and post-policy (red) era.
Figure 4.
Figure 4.
(a) DDLT and (b) waitlist mortality/dropout for HCC vs. non-HCC candidates in pre-policy (circle) and post-policy (square) era, stratified by UNOS region.
Figure 5.
Figure 5.
Cumulative incidence of all-cause graft failure over one year, pre-policy (blue) and post-policy (red), among HCC DDLT recipients. There was no evidence of change in post-transplant outcomes for HCC recipients (aHR=0.60 0.79 1.03, p=0.1).

Source: PubMed

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