MMaT-3 policy decreases survival, increases recurrence after transplant in HCC patients
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WASHINGTON — The MELD score at transplant minus three points policy led to poor survival and recurrence outcomes after liver transplantation among patients with hepatocellular carcinoma, according to research at The Liver Meeting.
“Patients with HCC have been disadvantaged by the use of MELD score for prioritization for liver transplant,” Anjiya Shaikh, MD, an internal medicine resident at the University of Connecticut, told attendees. “As we all know, MELD score is a good predictor for 3-month mortality in chronic liver disease patients. However, it doesn’t predict mortality due to cancer spread or tumor burden. That is why the [Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS)] implemented multiple allocation policies to grant HCC patients exception scores.”
She added, “Historically, however, these exception policies have overprioritized HCC patients for liver transplant compared to non-HCC patients.”
According to Shaikh, UNOS in 2015 implemented a 6-month delay from listing to receiving an exception score. Despite this delay, patients continued to receive over-prioritization, which led to the introduction of the MELD score at transplant minus three points (MMaT-3) policy in May 2019.
This policy “caps the exception score received to the median MELD at transplant minus three points after the six-month waitlist period,” Shaikh said.
Using data from the UNOS registry, Shaikh and colleagues compared post-transplant outcomes among 3,390 patients with HCC who underwent LT in the pre-MMaT era (56%; Aug. 2017-Nov. 2018) and the MMaT era (44%; June 2019-Aug. 2020). Researchers used a Cox regression analysis to determine the risk for post-transplant mortality and logistic regression to determine recurrence between groups.
According to results, 1-year post-transplant survival rates were 94.4% (95% CI, 93.4-95.2) and 91.6% (95% CI, 90.2-92.7) for pre-MMaT and MMaT eras, respectively. After adjusting for age, gender and race/ethnicity, researchers reported higher mortality among patients in the MMaT era cohort (adjusted HR = 1.35; 95% CI, 1.02-1.78).
Further, patients with HCC in the MMaT era had a 70% higher likelihood of recurrence (OR = 1.7; 95% CI, 1.33-2.17), and poorly differentiated HCC at explant increased threefold (sHR = 2.92; 95% CI, 1.58-5.4) after the policy change.
“While there was no change in survival amongst non-HCC patients, 1-year post-transplant survival in HCC patients in the MMaT era was significantly lower,” Shaikh concluded. “There are multiple confounding factors that could be contributing to this — it could be patient level, central level or treatment level factors. This remains unclear.”
She continued, “What we do know is that patients in the MMaT era are being transplanted at higher MELD score, they are receiving lower quality donors as seen by donation after cardiac death as well as high liver donor risk index and discard risk index, and a high proportion of explants have been found to be outside of the Milan criteria.”
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Shaikh A, et al. Abstract 7. Effect of the MMaT-3 policy on post-transplant outcomes. Presented at: The Liver Meeting; Nov. 4-8, 2022; Washington (hybrid).
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