Effects of the Share 35 Rule on Waitlist and Liver Transplantation Outcomes for Patients with Hepatocellular Carcinoma

Abstract

IntroductionSeveral studies have investigated the effects following the implementation of the “Share 35” policy; however none have investigated what effect this policy change has had on waitlist and liver transplantation (LT) outcomes for hepatocellular carcinoma(HCC).MethodsData were obtained from the UNOS database and a comparison of the 2 years post-Share 35 with data from the 2 years pre-Share 35 was performed.ResultsIn the pre-Share35 era, 23% of LT were performed for HCC exceptions compared to 22% of LT in the post-Share35 era (p = 0.21). No difference in wait-time for HCC patients was seen in any of the UNOS regions between the 2 eras. Competing risk analysis demonstrated that HCC candidates in post-Share 35 era were more likely to die or be delisted for “too sick” while waiting (7.2% vs. 5.3%; p = 0.005) within 15 months. A higher proportion of ECD (p<0.001) and DCD (p<0.001) livers were used for patients transplanted for HCC, while lower DRI organs were used for those patients transplanted with a MELD≥35 between the 2 eras (p = 0.007).ConclusionNo significant change to wait-time for patients listed for HCC was seen following implementation of “Share 35”. Transplant program behavior has changed resulting use of higher proportion of ECD and DCD liver grafts for patients with HCC. A higher rate of wait list mortality was observed in patients with HCC in the post-Share 35 era.

Liver transplant for hepatocellular carcinoma in the United States: Evolving trends over the last three decades

“…A study evaluating the effect of "Share 35" on patients who underwent LT for HCC demonstrated no change in the proportion of LT performed or overall waiting time. However, a higher rate of death/de-listing was observed (20). Similarly, in our study, we did not observe any significant change in the rate of LT for HCC in the Share 35 era, although our study did not specifically evaluate UNOS regional differences.…”

The Changing Landscapes in DCD Liver Transplantation

“…This potential shift is congruent with the principle of using extended criteria organs in recipients with lower biological MELD scores, such as many HCC patients, because of the perception that these recipients are better able to tolerate an extended criteria organ [ 21 ]. A previous publication demonstrated that after the implementation of the Share 35 policy, more HCC patients have received livers from DCD donors [ 22 ], potentially as the result of the highest quality organs being preferentially utilized by higher MELD recipients with broader sharing.…”

Donation After Circulatory Death Is Associated With Similar Posttransplant Survival in All but the Highest‐Risk Hepatocellular Carcinoma Patients

“…Historically, HCC patients have received a higher proportion of DCD donors than non‐HCC patients, which can be explained, in part, by an attempt to decrease wait‐list dropout for these patients, especially after the Share 35 rule was enacted. ( 29 ) However, in areas with organ shortages, wait‐list dropout rates for HCC patients are nearly 30%. ( 30 ) Expanding the pool of livers by using DCD donors has the potential to decrease this dropout rate, but properly selecting appropriate HCC candidates for DCD livers has been challenging.…”