1Hiram C Polk Jr Department of Surgery, Division of Transplantation, University of Louisville, Louisville, KY, USA.
Multiple studies have demonstrated an advantage for HCC patients under the current liver allocation system such that UNOS recently voted in support of a proposal to delay granting of MELD exception points for all HCC patients for 6 months, independently of a candidate's native MELD score or alpha fetoprotein (AFP) level. We obtained UNOS data on adult patients added to the waitlist from 1/22/2005-9/30/2009 so as to explore the relationship between HCC, MELD, AFP and other factors that contribute to not only dropout on the waitlist but post-transplant survival as well. The aim was to establish an equivalent MELD score (MELDEQ ) for HCC patients that would reduce the disparity in access to transplantation between HCC and non-HCC patients. We determined risk groups for HCC patients with equivalent dropout hazards to non-HCC patients and evaluated projections for HCC waitlist dropout/transplantation probabilities based on the MELDEQ prioritization scheme. Projections indicate that lower-risk HCC patients (MELDEQ ≤ 18) would have dropout probabilities similar to non-HCC patients in the same MELD score range, while dropout probabilities for higher-risk HCC patients would actually be improved. Post-transplant survival of all HCC risk groups is lower than their non-HCC counterparts, with one-year survival of 0.77 (95% CI 0.70-0.85) for MELDEQ ≥ 31. These results suggest that HCC patients with a combined low biochemical MELD and low AFP (MELDEQ ≤ 15) receive a marked advantage compared to patients with chemical MELDs in a similar range, and a delay of 6 months for listing may be appropriate. In contrast, patients with MELDEQ scores > 15 would likely be adversely impacted by a universal 6 month delay in listing.