Given the increasing incidence of hepatocellular carcinoma (HCC) and regional differences in liver transplant (LT) rates for HCC, we used the United Network for Organ Sharing (UNOS) database to investigate temporal and geographic trends in LT and waitlist dropout (death or delisting without LT) in HCC patients meeting Milan criteria who received MELD exception from 2005 to 2014. Among 14,320 patients included, 33% were listed in long wait time regions (LWR-1,5,9), 43% in medium wait time regions (MWR-2,4,6,7,8), and 24% in short wait time regions (SWR-3,10,11). HCC registrations increased from 43% during 2005-2009 to 57% in 2010-2014. Overall, 73% underwent LT and 15% had waitlist dropout. From 2005-2009 to 2010-2014, median time to LT increased by 6.0 months (5.6 to 11.6) in LWR compared to 3.8 months (2.6 to 6.4) in MWR and 1.3 months (1.0 to 2.3) in SWR (p<0.001). While accounting for competing risks (CR), the 3-year probability of LT was 70% in LWR vs 81% in MWR and 91% in SWR, and the 3-year probability of waitlist dropout was 24% in LWR vs 16% in MWR and 8% in SWR (p<0.001). LWR also had a significantly greater increase in the probability of dropout from 2005-2009 to 2010-2014 compared to MWR and SWR (p<0.001). Predictors of waitlist dropout by CR regression included LWR (SHR 3.5, 95% CI 3.0-4.0, p<0.001) and MWR (SHR 2.2, 95% CI 1.9-2.6, p<0.001) compared to SWR, and listing year 2010-2014 (SHR 1.9, 95% CI 1.7-2.0, p<0.001). Other predictors of dropout were increasing age, alpha-fetoprotein >20 ng/ml, MELD >15, and a single 3.1-5 cm tumor or multiple tumors compared to a single 2-3 cm tumor. Local regional therapy and hepatitis B (vs hepatitis C) predicted a lower dropout risk. From 2005-2009 to 2010-2014, intention-to-treat 3-year survival decreased from 69% to 63% in LWR (p<0.001), from 72% to 69% in MWR (p=0.008), and remained 74% in SWR (p=0.48). In conclusion, we observed a significant increase in waitlist dropout in HCC patients in recent years that disproportionately impacted patients in LWR. The widening geographical disparities further support the need for redistricting or assigning variable MELD exception points by region.

CITATION INFORMATION: Mehta N, Sarkar M, Dodge J, Hirose R, Roberts J, Yao F. Increasing Liver Transplant Waitlist Dropout for Hepatocellular Carcinoma with Widening Geographical Disparities: Implications for Organ Allocation. Am J Transplant. 2017;17 (suppl 3).

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