Racial-ethnic differences in liver transplant waitlist outcomes in patients with hepatocellular carcinoma before and after recent changes to allocation policy.

Abstract

In May 2019, liver transplant (LT) allocation policy changed to limit MELD exception points for hepatocellular carcinoma (HCC) to median MELD at transplant minus three (MMaT-3). We evaluated this policy's impact on waitlist outcomes for HCC candidates, by race and ethnicity, hypothesizing that the introduction of the MMaT-3 reduced inequities in waitlist outcomes. Retrospective cohort study of the Scientific Registry for Transplant Recipients, including all adult LT candidates (N=10751) who received HCC exception points from May 17, 2017 to May 18, 2019 (pre-policy; N=6627) to May 19, 2019 to March 1, 2021 (post-policy; N=4124). We compared incidence of LT and waitlist removal for death or becoming too sick pre- and post-policy for non-Hispanic White, non-Hispanic Black, Hispanic/Latinx, and Asian patients using competing risk regression adjusted for candidate characteristics. One-year cumulative incidence of LT decreased significantly pre-/post-policy among White (77.4%vs. 64.5%; p<.01) and Black (76.2%vs. 63.1%; p<.01) candidates only, while a 1-year incidence of death/non-LT waitlist removal decreased significantly only among Hispanics (13.4%vs. 7.5%; p<.01). After covariate adjustment, the effect of the policy change was a significantly decreased incidence of LT for White (SHR:.63 compared to pre-policy; p<.001), Black (SHR:.62; p<.001), and Asian (SHR:.68; p=.002), but no change for Hispanic patients. Only Hispanic patients had a significant decrease in death/waitlist removal after the policy change (SHR: .69; p=.04). Compared to White patients in the pre-policy era, Hispanic (SHR: .88, p<.007) and Asian candidates (SHR: .72; p<.001) had lower unadjusted incidence of LT. This disparity was mitigated in the post-policy era where Hispanic patients had higher likelihood of LT than Whites (SHR: 1.22; p=.002). For the outcome of death/non-LT waitlist removal, the only significant difference was a 42% lower incidence of waitlist removal for Asian compared to White patients in the post-policy era (SHR: .58; p=.03). Among LT recipients with HCC, racial/ethnic subpopulations were differentially affected by the MMAT-3 policy, resulting in a post-policy reduction of some of the previous disparities.