Liver transplantation for hepatocellular carcinoma: Impact of the MELD allocation system and predictors of survival

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 20022007, 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 a-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 a-fetoprotein level >= 455 ng/mL, or a MELD score >= 20 have poor posttransplantation survival.