Liver Transplantation for Hepatocellular Carcinoma: Impact of the MELD Allocation System and Predictors of Survival

doi:10.1053/j.gastro.2008.02.013

Gastroenterology

Volume 134, Issue 5, May 2008, Pages 1342-1351

https://doi.org/10.1053/j.gastro.2008.02.013 Get rights and content

Background & Aims: Since February 27, 2002, patients with early-stage hepatocellular carcinoma (HCC) have received priority for liver transplantation in the United States under the Model for End-Stage Liver Disease (MELD) allocation system. We aimed to determine the impact of this system on liver transplantation for HCC. Methods: Data were provided by the United Network for Organ Sharing on 19,404 first-time, cadaveric, adult liver transplantations performed in the United States between 2002 and 2007 and 15,906 performed between 1997 and 2002, an equal-duration period immediately preceding the MELD allocation system. Results: In 1997–2002, 4.6% of liver transplant recipients had HCC compared with 26% in 2002–2007, the majority of whom received “HCC-MELD-exceptions” allowing expedited transplantation. Posttransplantation survival of patients with HCC without an “HCC-MELD-exception” was significantly worse than the survival of patients without HCC. In 2002–2007, patients with an “HCC-MELD-exception” had similar survival to patients without HCC. However, for the subgroup of patients with tumors 3–5 cm in size had significantly worse survival. When compared with patients with similar MELD scores, patients in the “HCC-MELD-exception” group had worse posttransplantation survival than patients without HCC. The most important predictors of poor posttransplantation survival were MELD score ≥20 (hazard ratio, 1.61; 95% CI: 1.3–2.1) and serum α-fetoprotein level ≥455 ng/mL (hazard ratio, 2.15; 95% CI: 1.5–2.0). Conclusions: The adoption of the MELD allocation system has led to a 6-fold increase in the proportion of transplantation patients with HCC. Patients with larger (3–5 cm) tumors, serum α-fetoprotein level ≥455 ng/mL, or a MELD score ≥20 have poor posttransplantation survival.

Section snippets

Data Collection

Transplant centers and organ procurement organizations in the United States are required to submit standardized data collection forms to the UNOS,¹² including the “Transplant Candidate Registration Form,” which contains patient information at the time of listing for liver transplantation; the “Deceased Donor Registration Form,” which contains information on all consented recovered and nonrecovered donors; the “Transplant Recipient Registration Form,” which includes the patient status at

Results

Among the 15,906 liver transplant recipients in 1997–2002, only 731 (4.6%) had a diagnosis of HCC (Table 1). The proportion of liver transplant recipients with HCC in 2002–2007 (5045/19,404 or 26%) increased almost 6-fold. This was exclusively due to the large number of patients (n = 4453) who underwent liver transplantation in 2002–2007 with an “HCC-MELD-exception” from the MELD score priority system because of the presence of HCC. During both time periods, patients with HCC were more likely

Discussion

Our study demonstrates that the introduction of the MELD-based priority system in February 2002 allowing high priority scores for patients with HCC resulted in a 6-fold increase in the proportion of liver transplant recipients with HCC. More than a quarter of liver transplant recipients in the United States in 2002–2007 had HCC, the vast majority of whom received a liver transplant using an exception from the MELD-based priority system.

Our study also suggests that the introduction of the MELD

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