Increasing disparity in waitlist mortality rates with increased model for end-stage liver disease scores for candidates with hepatocellular carcinoma versus candidates without hepatocellular carcinoma

Authors

  • David Goldberg,

    Corresponding author
    1. Division of Gastroenterology, Department of Medicine,University of Pennsylvania, Philadelphia, PA
    2. Clinical Center for Epidemiology and Biostatistics,University of Pennsylvania, Philadelphia, PA
    • Division of Gastroenterology, Department of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 9 Penn Tower, Philadelphia, PA 19104
    Search for more papers by this author
    • Telephone: 215-746-8598; FAX: 215-349-5915

  • Benjamin French,

    1. Clinical Center for Epidemiology and Biostatistics,University of Pennsylvania, Philadelphia, PA
    2. Leonard Davis Institute for Health Economics,University of Pennsylvania, Philadelphia, PA
    Search for more papers by this author
  • Peter Abt,

    1. Division of Transplantation, Department of Surgery, University of Pennsylvania, Philadelphia, PA
    Search for more papers by this author
  • Sandy Feng,

    1. Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA
    Search for more papers by this author
  • Andrew M. Cameron

    1. Comprehensive Transplant Center, Johns Hopkins University School of Medicine, Baltimore, MD
    Search for more papers by this author

  • This study was supported by the National Institutes of Health (grant 1-F32-DK-089694-01 from the National Institute of Diabetes and Digestive and Kidney Diseases to David Goldberg) and by the Health Resources and Services Administration (contract 234-2005-370011C). The contents of this article are the responsibility of the authors alone and do not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.

  • See Editorial on Page 381

Abstract

Candidates with hepatocellular carcinoma (HCC) within the Milan criteria (MC) receive standardized Model for End-Stage LIver Disease (MELD) exception points because of the projected risk of tumor expansion beyond the MC. Exception points at listing are meant to be equivalent to a 15% rusj if 90-day mortality, with additional points granted every 3 months, equivalent to a 10% increased morality risk. We analyzed the United Network for Organ Sharing database (January 1, 2005 to May 31, 2009) to compare the 90-day waitlist outcomes of HCC candidates and non-HCC candidates with similar MELD scores. Two hundred fifty-nine HCC candidates (4.1%) who were initially listed with 22 MELD exception points were removed because of death or clinical deterioration within 90 days of listing, whereas 283 non-HCC candidates (11.0%) with initial laboratory MELD scores of 21 to 23 were removed. Ninety-three HCC candidates (4.6%) with 25 exception points (after 3-6 months of waiting) were removed because of death or clinical deterioration within 90 days, whereas 805 non-HCC candidates (17.3%) with laboratory MELD scores of 24 to 26 were removed. Twenty HCC candidates (3.0%) with 28 exception points (after 6-9 months of waiting) were removed for death or clinical deterioration within 90 days, whereas 646 non-HCC candidates (23.6%) with laboratory MELD scores of 27 to 29 were removed. In multivariate logistic regression models, HCC candidates had significantly lower 90-day odds of waitlist removal for death or clinical deterioration (P < 0.001). Over time, the risk of waitlist removal for death or clinical deterioration was unchanged for HCC candidates (P = 0.17), whereas it increased significantly for non-HCC candidates. The current allotment of HCC exception points should be re-evaluated because of the stable risk of waitlist dropout for these candidates. Liver Transpl 18:434–443, 2012. © 2012 AASLD.

Ancillary