title: 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.
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.
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA. david.goldberg@uphs.upenn.edu
authors.forename: David
authors.initials: D
authors.lastname: Goldberg
authors.forename: Benjamin
authors.initials: B
authors.lastname: French
authors.forename: Peter
authors.initials: P
authors.lastname: Abt
authors.forename: Sandy
authors.initials: S
authors.lastname: Feng
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Cameron
mesh_terms: D000328:Adult; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D016009:Chi-Square Distribution; D018450:Disease Progression; D005260:Female; D006305:Health Status Indicators; D006801:Humans; D008107:Liver Diseases / Q000175:diagnosis / Q000401:mortality / Q000473:pathology / Q000601:surgery; D008113:Liver Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000473:pathology / Q000601:surgery; D016031:Liver Transplantation / Q000401:mortality*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010352:Patient Dropouts; D018579:Patient Selection; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D016019:Survival Analysis; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D014850:Waiting Lists / Q000401:mortality*