LIVER TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA: IMPLICATIONS OF EXPANDING AGE LIMITS IN LOW-DONATION SETTINGS IN LATIN AMERICA

Abstract

Introduction and Objectives

In Costa Rica, liver transplantation (LT) for hepatocellular carcinoma (HCC) is legally restricted to patients under 65 years. This limits curative options and may favor patients receiving exception MELD points. The country’s average liver donation rate remains low, at 5.4 donors per million population per year, further limiting access.

Materials and Methods

We assessed transplant eligibility, bridging therapies, and outcomes in HCC patients at a tertiary center. Eligibility was defined as age <65, meeting UCSF criteria, and having no contraindications. We modeled the impact of raising the age limit to <70 years.

Results

Of 260 patients, 52 (20%) met transplant criteria; 86.5% received bridging therapy (TACE 27, ablation 18, resection 2). One additional patient was downstaged to eligibility. Among 53 total candidates, 30.2% progressed or died before listing, 11.3% remained stable on alternative treatments, 45% were transplanted, and 9.4% died or dropped out while on the waitlist. Mean wait time was 148.1 days (SD 93.5). Expanding the age limit to <70 years would increase eligibility by 49%, adding 27 candidates. However, this may disadvantage other patients with high functional MELD scores, as those with HCC receive exception points after three months of evaluation.

Conclusions

Raising the age threshold for LT would expand access for older HCC patients but may exacerbate inequities in organ allocation due to low donation rates and MELD exception prioritization. Policy reform must be accompanied by increased organ procurement efforts and ethical safeguards to ensure equitable access in low-donation settings such as Costa Rica.