Background – The current UNOS allocation system gives priority to patients with HCC to receive livers. This can potentially cause significant regional disparities in organ access and possibly outcomes in this population. Our aim was to assess these disparities by comparing outcomes in regions with high waiting times (5 and 9) and low waiting times (3 and 10).

Methods – Analysis of 6,160 HCC patients that received exception points on the UNOS database in regions 3,5,9 and 10 from 2002 to 2012. Data from regions 5 and 9 were combined and compared to date from regions 3 and 10. Survival curves, multivariable analysis and log rank testing was used to analyze the data.

Results – Median time on the list in the high waiting time regions (HWR) was 7.5 months compared to 1.5 months for low waiting time regions (LWR) with a significantly higher rate of deaths on the waiting list in HWR than in LWR (8% vs 2%, p<0.0001). Patients in LWR were more likely to undergo loco-regional therapies than patients in HWR (45% vs 38%, p<0.0001). Patients who were listed and transplanted in HWR had significantly better overall survival than patients in LWR (p=0.01). When the survival data were stratified by lab MELD – patients with lower MELDs (6-14) were found to be the only group to benefit from waiting longer when compared to medium (15-22) and high (>22) MELD patients (HWR vs LWR – Low MELD p<0.0001, Medium MELD p= NS, High MELD, p=NS).

Multivariate analysis of factors influencing overall survival showed that being listed/transplanted in a low waiting time region was an independent predictor of worse outcome (p<0.0001, HR 1.52 CI 1.35-1.79).

Conclusion – Our study shows that allocation of exception points for HCC in regions with lower waiting times and prioritization of liver allocation in these regions results in worse outcomes. This calls for a change in the current UNOS allocation policy to reflect this disparity among geographic regions in the US.

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