Hepatocellular Carcinoma Patients Are Advantaged in the Current Brazilian Liver Transplant Allocation System. A Competing Risk Analysis

Abstract

BACKGROUND: In Brazil, the Model for End-Stage Liver Disease (MELD) score is used to prioritize patients for deceased donor liver transplantation (DDLT). Patients with hepatocellular carcinoma (HCC) receive standardized MELD exception points to account for their cancer risk of mortality, which is not reflected by their MELD score. OBJECTIVE: To compare DDLT rates between patients with and without HCC in Rio Grande do Sul, the Southernmost state of Brazil. METHODS - We retrospectively studied 825 patients on the liver-transplant waiting list from January 1, 2007, to December 31, 2016, in a transplant center located in Porto Alegre, the capital of Rio Grande do Sul, to compare DDLT rates between those with and without HCC. The time-varying hazard of waiting list/DDLT was estimated, reporting the subhazard ratio (SHR) of waiting list/DDLT/dropout with 95% confidence intervals (CI). The final competing risk model was adjusted for age, MELD score, exception points, and ABO group. RESULTS: Patients with HCC underwent a transplant almost three times faster than patients with a calculated MELD score (SHR 2.64; 95% CI 2.10-3.31; P<0.001). The DDLT rate per 100 person-months was 11.86 for HCC patients vs 3.38 for non-HCC patients. The median time on the waiting list was 5.6 months for patients with HCC and 25 months for patients without HCC. CONCLUSION: Our results demonstrated that, in our center, patients on the waiting list with HCC have a clear advantage over candidates listed with a calculated MELD score.

Liver transplantation for hepatocellular carcinoma: impact of expansion criteria in a multicenter cohort study from a high waitlist mortality region

“…Patients with HCC on the other hand had lower dropout rates (3.8% vs. 6.7%) and higher transplant access (83% vs. 57%) [12]. Similar results have been reported in Brazil [15,28]. We evaluated potential effects of adopting any of the policies described above to organ allocation in the Argentine National Registry and found that Milan–UCSF‐DS policy would have increased number of HCC transplanted patients by 10.9% and the AFP score would have increased the number by 3.3%.…”

“…In Latin America, previous reports have shown lower donation rates per million population (pmp) compared with those reported in Europe and the United States of America (8.3 pmp vs. 15 pmp and 26 pmp, respectively) [13,14]. Moreover, within Milan criteria, HCC patients are granted transplant benefit, showing significantly lower waitlist mortality compared with non‐HCC patients [12,15]. Consequences of adopting expansion criteria policies in regions with high waitlist mortality have not been previously reported.…”

Meld Exception Points Provide an Enourmous Advantage for Receiving a Liver Transplant in Brazil

“…A Brazilian single center analysis revealed that the prevalence of HCC among patients undergoing LT was higher in the post-MELD era as compared to the pre-MELD era (20) . However, a recent study evaluating on the outcomes of enlisted patients from the other liver transplant center from Porto Alegre also revealed that HCC patients confirmed that that HCC patients were transplanted fasted and at a higher rate than CIR patients (21) . Unfortunately, except from few studies performed in the USA, multicenter studies evaluating the dynamics of the LT waiting list are lacking (22)(23)(24) .…”

Liver Transplantation in Brazil: The Urgent Need of a New Allocation System for the Exceptions in Meld Score

“…When we give the same extra points for so different regionals, different conditions, different blood types, we generate big discrepancies, giving privileges to certain patients and neglecting others. One example is the big advantage of HCC patients over the other chronic liver diseases in terms of transplantation, especially in states where the MELD score needed for being transplanted is much lower (5) . The issue becomes even worse when HCC patients with higher socioeconomical levels migrate from a "big list state" to a "small list state", where they are transplanted very fast and probably before than a local chronic disease patient, increasing even more this discrepancy.…”

“…The discussion about the advantage of HCC patients and other MELD exceptions over the chronic disease patients has been brought in Brazilian meetings and publications (5,6) , nevertheless it has not resulted in any effective measure to improve the system. Instead, frequently the discussions come out with wrong conclusions, as that we cannot expand Milan Criteria in Brazil, even for HCC patients with similar survival and good tumor biology, because HCC patients have already an "advantage".…”