Delisting From Liver Transplant List for Improvement and Re-compensation Among Decompensated Patients at one-year.

Abstract

Background and aim: Data are limited regarding etiology-specific trends for delisting and re-compensation for liver disease improvement among liver transplant (LT) listed candidates in the US.

Methods and results: A retrospective cohort (2002-2022) using UNOS database examined etiology-specific trends for delisting and re-compensation due to liver disease improvement among candidates listed for LT. Of 120,451 listings in adults, 34,444 (2002-08), 38,296 (2009-2015), 47,711 (2016-2022) were analyzed. A total of 7196 (6.2%) were delisted for liver disease improvement, with 5.6, 7.2, 5.3% in three respective time periods, Armitage trend p<0.001. Delisting for improvement of liver disease was 8.1, 5.8, 4.0, 3.9, and 3.1% among listings for alcohol-associated liver disease (ALD n=41,647), hepatitis C virus infection (HCV n=38,797), autoimmune (n=12,131), metabolic associated steatotohepatitis (MASH n=22,162), hepatitis B virus infection (HBV n=3027), and metabolic liver disease (MLD n=2687) respectively. 1122 (15.6% or 0.9%) delisted for improvement at 1-yr. with cumulative incidence competing for waitlist mortality and receipt of LT of 1.18, 1.17, 0.64, 0.59, 0.50, 0.34 for ALD, HBV, HCV, MASH, MLD, and autoimmune respectively. In a fine and gray model, compared to metabolic, sub-hazard ratio (95% CI) on delisting at 1-yr. was 3.47 (31.6-3.81) and 3.44 (2.96-3.99), P<0.001 for ALD and for HBV respectively. Of 7196 delisting for improvement, 567 of 5750 (9.9%) decompensated at listing had re-compensation, 19.5% for HBV, 16.6% MLD and autoimmune, 9.9% ALD, 8.6% for HCV, and 6.9% MASH. In a logistic regression model among delisted candidates for improved liver disease, HBV vs. MASH etiology was associated with re-compensation, 2.37 (1.40-4.03), P<0.001.

Conclusion: ALD and HBV are most frequent etiologies for delisting due to liver disease improvement. About 10% of delisted patients develop re-compensation, with HBV etiology most likely to recompensate. Models and biomarkers are needed to identify these candidates for optimal use of deceased donor livers.