Historically, exception points for hepatocellular carcinoma (HCC) led to higher transplant rates and lower waitlist mortality 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 (10/8/2013-10/7/2015, pre-policy) and after (10/8/2015-10/7/2017, post-policy) 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 pre-policy (aHR= 3.49 3.69 3.89 ) and a 2.2-fold higher rate of DDLT post-policy (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 post-policy (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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