Background: In the US, wait-list dropout is lower and the transplant rate higher for candidates with standard MELD exception for hepatocellular carcinoma (HCC) than for candidates without MELD exception. As 27.4% of liver transplants in 2011 were in candidates with standard HCC exception, this affects access to transplant for non-HCC candidates. We aimed to model the impact of changes to HCC MELD exception to determine the impact on wait-list dropout and transplant rates for HCC vs. non-HCC candidates.

Methods: In SRTR data for all wait-listed candidates 1/1/2010-12/31/2010 (n=28,053), 2773 candidates (9.9%) had an HCC MELD exception at some time point. The impact of a 3- or 6-month delay in receiving a MELD score exception, capped at a maximum of 29 or 31 HCC MELD achieved, or of varying the initial HCC MELD score to the median MELD for that region, was analyzed using liver simulated allocation modeling.

Results: Based on the model, a 6-month delay in receiving HCC MELD exception would result in a nearly equal transplant rate for HCC (39.57 transplants/100 person years) and non-HCC (34.74) candidates; a 3-month delay would reduce the current transplant rate disparity of 114.43 for HCC vs. 30.25 for non-HCC candidates by approximately half, to 58.77 for HCC vs. 33.34 for non-HCC (Figure). A 3- or 6-month delay did not affect the total number of transplants or the total wait-list death/removal rate (current 2265 deaths/removals vs. 2267 for 3-month delay and 2240 for 6-month delay.) The transplant rate disparity was not improved by use of a variable initial HCC exception, or by use of a MELD cap of 29 or 31 alone or in combination (Figure).

Conclusions: A delayed initial HCC MELD score exception may allow for more equal access to liver transplant for candidates with and without HCC MELD score exception.

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