Delayed hepatocellular carcinoma model for end-stage liver disease exception score improves disparity in access to liver transplant in the United States

Abstract

The current system granting liver transplant candidates with hepatocellular carcinoma (HCC) additional Model for End-Stage Liver Disease (MELD) points is controversial due to geographic disparity and uncertainty regarding optimal prioritization of candidates. The current national policy assigns a MELD exception score of 22 immediately upon listing of eligible patients with HCC. The aim of this study was to evaluate the potential effects of delays in granting these exception points on transplant rates for HCC and non-HCC patients. We used Scientific Registry of Transplant Recipients data and liver simulated allocation modeling software and modeled (1) a 3-month delay before granting a MELD exception score of 25, (2) a 6-month delay before granting a score of 28, and (3) a 9-month delay before granting a score of 29. Of all candidates waitlisted between January 1 and December 31, 2010 (n = 28,053), 2773 (9.9%) had an HCC MELD exception. For HCC candidates, transplant rates would be 108.7, 65.0, 44.2, and 33.6 per 100 person-years for the current policy and for 3-, 6-, and 9-month delays, respectively. Corresponding rates would be 30.1, 32.5, 33.9, and 34.8 for non-HCC candidates.

Conclusion: A delay of 6-9 months would eliminate the geographic variability in the discrepancy between HCC and non-HCC transplant rates under current policy and may allow for more equal access to transplant for all candidates.

Figure 1

Panel A. Median match MELD at liver transplant and the gap in transplant rates between HCC and non-HCC patients by region. In regions where patients undergo transplant at lower MELD scores, the disparity between HCC and non-HCC patients was larger than in high MELD regions. Each dot represents one of the 11 OPTN regions. Panel B. Effect of 6- and 9-month delays in application of HCC exception scores on the gap in transplant rates between HCC and non-HCC patients by region. The negative correlation seen in Panel A is no longer apparent. HCC, hepatocellular carcinoma; MELD, model for end-stage liver disease; OPTN, Organ Procurement and Transplantation Network.