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

Ishaque, Tanveen; Massie, Allan B.; Bowring, Mary G.; Haugen, Christine E.; Ruck, Jessica M.; Halpern, Samantha E.; Waldram, Madeleine M.; Henderson, Macey L.; Garonzik-Wang, Jacqueline; Cameron, Andrew M.; Philosophe, Benjamin; Ottmann, Shane; Rositch, Anne F.; Segev, Dorry L.

doi:10.1111/ajt.15144

Cited by 61 publications

(55 citation statements)

References 14 publications

(16 reference statements)

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“…In a study published in October 2018 by the Baltimore group, the transplant rate for HCC remained higher than for non-HCC patients (HR ¼ 2.1 [2.09-2.34]) but had decreased compared with the prepolitical period (HR ¼ 3.69 [3.49-3.89]). 70 In addition, the risk of delisting and mortality before and after policy update was lower than that of non-HCC patients (HR ¼ 0.63 [0.54-0.73]) whereas it was comparable after the implementation of the new policy (HR ¼ 0.91 [0.81-1.1]). These results, while encouraging in terms of equity and equal access to transplantation, still tend to show that there is currently no system in place to accurately balance transplantation for decompensated cirrhosis and HCC.…”

Section: Hepatocellular Carcinomamentioning

confidence: 99%

A Critical Review of MELD as a Reliable Tool for Transplant Prioritization

Sacleux

Samuel

2019

Semin Liver Dis

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In a context of global organ shortage, the Model for End-Stage Liver Disease (MELD) score seems to be a fair prioritization tool, with a paradigm: “sickest first.” Since its introduction in the United States in 2002, it has been rapidly adopted by transplant centers and organ sharing agencies around the world. The MELD score showed its effectiveness with a 12% reduction in waiting list mortality in the United States. Its success is linked to its simplicity, the use of basic variables (serum creatinine, serum bilirubin, and international normalized ratio [INR]), and its ability to predict short-term mortality, particularly on the transplant waiting list. However, this score is not perfect: its variables may have disadvantages for some patients, especially women, with serum creatinine and interlaboratory variability of the INR. The MELD score does not take into account some variables associated with poor short-term prognosis in cirrhotic patients. In addition, it is currently capped at 40, which results in the exclusion of sicker patients who could greatly benefit from transplantation. Finally, the MELD score does not accurately reflect the prognosis of several conditions, requiring a MELD exception system. Some solutions have been suggested such as MELD-Na or MELD uncapping, but it has not yet been fully accepted by all transplant centers.

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Section: Hepatocellular Carcinomamentioning

confidence: 99%

A Critical Review of MELD as a Reliable Tool for Transplant Prioritization

Sacleux

Samuel

2019

Semin Liver Dis

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“…Ishaque et al demonstrated that 2015 updates to the HCC policy accomplished the goal of reducing the differences in rates of HCC and non‐HCC wait‐list mortality/dropout at a national level. This change was largely driven by an increased risk of wait‐list dropout for HCC patients compared with non‐HCC patients with HR increasing from 0.8 before to 1.9 after policy implementation.…”

Section: Discussionmentioning

confidence: 99%

“…A recent analysis by Ishaque et al showed the 2015 policy changes of a 6‐month exception delay and MELD cap achieved their goal, at least at a national level. In the 2 years preceding the revision, HCC patients had a 37% lower wait‐list mortality/dropout rate versus non‐HCC patients (hazard ratio [HR], 0.63 95% CI 0.54‐0.73) compared with a nearly equitable wait‐list mortality/dropout rate after policy implementation (HR, 0.95 95% CI 0.81‐1.11) . To our knowledge, no regional analysis of post‐2015 wait times has been completed, and therefore, the impact of this policy change on the wait‐list mortality and dropout rates in SWRs versus mid‐wait regions (MWRs) versus LWRs remains unknown.…”

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Unfair Advantages for Hepatocellular Carcinoma Patients Listed for Liver Transplant in Short‐Wait Regions Following 2015 Hepatocellular Carcinoma Policy Change

et al. 2020

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For patients with hepatocellular carcinoma (HCC) listed for liver transplantation (LT), United Network for Organ Sharing (UNOS) enacted policy changes in 2015 to improve equity between HCC and non-HCC patients.We evaluated the impact of these changes on regional disparities in wait-list dropout and LT. We included patients in the UNOS database listed with Model for End-Stage Liver Disease HCC exceptions in long-wait regions (LWRs), mid-wait regions (MWRs), and shortwait regions (SWRs) before these policy changes (era 1, January 1 to December 31, 2013) and after (era 2, October 7, 2015, to October 7, 2016). Cumulative incidence of wait-list dropout and LT were evaluated using competing risk regression. Median time to LT increased by 3.6 months (3.1 to 6.7 months) in SWRs and 1.3 months (6.9 to 8.2 months) in MWRs (P < 0.001), with a slight decrease in LWRs (13.4 to 12.9 months; P = 0.02). The 2-year cumulative incidence of dropout increased from 9.7% to 14.8% in SWRs (P = 0.03) and from 18.9% to 22.6% in MWRs (P = 0.18) but decreased in LWRs from 26.7% to 24.8% (P = 0.31). Factors predicting wait-list dropout included listing in era 2 (hazard ratio [HR], 1.17), in LWRs (HR, 2.56), and in MWRs (HR, 1.91). Regional differences in wait-list outcomes decreased with policy changes, but HCC patients in SWRs remain advantaged. Recent policy change may narrow these disparities. Liver Transplantation 26 662-672 2020 AASLD.The United Network for Organ Sharing (UNOS) introduced the Model for End-Stage Liver Disease (MELD) priority exception system for hepatocellular carcinoma (HCC) in 2002 to establish equitable dropout rates between HCC and non-HCC patients awaiting liver transplantation (LT). (1) Even with policy adjustments in 2003 and 2005, HCC patients continued to receive excess priority (2)(3)(4) and an unfair advantage in access to LT compared with non-HCC patients. Specifically, the 12-month wait-list dropout over a 3-year span from 2005 to 2008 was 11.5% for HCC patients versus 17.7% for all non-HCC patients nationally. (2) Thus, UNOS introduced additional revisions in October 2015: a 6-month delay in awarding HCC exception points and a MELD exception cap at 34 points. (5) These changes reflected simulation data that predicted that a 6-month delay would promote equity between HCC and non-HCC patients. (6) BrOndfield et al.

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“…( 3,10,11 ) However, wait‐list prioritization and the assignment of MELD exception points are identical for both diagnosis groups. Although several studies have reported a wait‐list advantage among HCC patients who received exception points over non‐HCC patients who never received exception points, ( 12‐15 ) no comparative study of wait‐list mortality/delisting for being too ill of CCA and HCC cohorts has been performed among candidates whose prioritization for LT is based on MELD exception.…”

mentioning

confidence: 99%

Comparison of Wait‐List Mortality Between Cholangiocarcinoma and Hepatocellular Carcinoma Liver Transplant Candidates

Ziogas¹,

Hickman²,

Matsuoka³

et al. 2020

Liver Transpl

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Despite the divergent disease biology of cholangiocarcinoma (CCA) and hepatocellular carcinoma (HCC), wait‐list prioritization is identical for both diagnoses. We compared wait‐list and posttransplant outcomes between CCA and HCC liver transplantation patients with Model for End‐Stage Liver Disease exceptions using Scientific Registry of Transplant Recipients data. The 408 CCA candidates listed between 2003 and mid‐2017 were matched to 2 HCC cohorts by listing date (±2 months, n = 816) and by Organ Procurement and Transplantation Network (OPTN) region and date (±6 months, n = 408). Cumulative incidence competing risk regression examined the effects of diagnosis, OPTN region, and center‐level CCA listing volume on wait‐list removal due to death/being too ill (dropout). Cox models evaluated the effects of diagnosis, OPTN region, center‐level CCA volume, and waiting time on graft failure among deceased donor liver transplantation (DDLT) recipients. After adjusting for OPTN region and CCA listing volume (all P ≥ 0.07), both HCC cohorts had a reduced likelihood of wait‐list dropout compared with CCA candidates (HCC with period matching only: subdistribution hazard ratio [SHR] = 0.63; 95% CI, 0.43‐0.93; P = 0.02 and HCC with OPTN region and period matching: SHR = 0.60; 95% CI, 0.41‐0.87; P = 0.007). The cumulative incidence rates of wait‐list dropout at 6 and 12 months were 13.2% (95% CI, 10.0%‐17.0%) and 23.9% (95% CI, 20.0%‐29.0%) for CCA candidates, 7.3% (95% CI, 5.0%‐10.0%) and 12.7% (95% CI, 10.0%‐17.0%) for HCC candidates with region and listing date matching, and 7.1% (95% CI, 5.0%‐9.0%) and 12.6% (95% CI, 10.0%‐15.0%) for HCC candidates with listing date matching only. Additionally, HCC DDLT recipients had a 57% reduced risk of graft failure compared with CCA recipients (P < 0.001). Waiting time was unrelated to graft failure (P = 0.57), and there was no waiting time by diagnosis cohort interaction effect (P = 0.47). When identically prioritized, LT candidates with CCA have increased wait‐list dropout compared with those with HCC. More granular data are necessary to discern ways to mitigate this wait‐list disadvantage and improve survival for patients with CCA.

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

Cited by 61 publications

References 14 publications

A Critical Review of MELD as a Reliable Tool for Transplant Prioritization

A Critical Review of MELD as a Reliable Tool for Transplant Prioritization

Unfair Advantages for Hepatocellular Carcinoma Patients Listed for Liver Transplant in Short‐Wait Regions Following 2015 Hepatocellular Carcinoma Policy Change

Comparison of Wait‐List Mortality Between Cholangiocarcinoma and Hepatocellular Carcinoma Liver Transplant Candidates

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