Procurement Versatility and Waitlist Outcomes in Patients With Hepatocellular Carcinoma

Introduction: Liver transplantation is curative for hepatocellular carcinoma (HCC) but organ scarcity and allocation methods pose challenges. Transplant center procurement versatility through use of static cold storage (SCS), living donor liver transplantation (LDLT), and machine perfusion (MP) may decrease waitlist death and delisting (DDL). Methods: We performed a retrospective review of HCC patients added to the liver transplantation waitlist between February 2020 and December 2023 identified using the Organ Procurement and Transplantation Network database. Centers were stratified as performing SCS, SCS and MP (MP), SCS and LDLT (LDLT), and all modalities (SCS, MP, and LDLT). Patient and center factors associated with DDL were analyzed. Results: 8358 patients with HCC were listed for liver transplantation. The waitlist DDL rate was 22.4%. Good functional status (hazard ratio [HR] 0.40, P < 0.01) and female sex (HR 0.74, P < 0.01) were protective of waitlist DDL. Patients at SCS centers had the highest rate of waitlist DDL (26.2%), while those at MP centers had the lowest (19.7%). Listing at MP (HR 0.83, P < 0.01) and SCS, MP, and LDLT centers (HR 0.80, P < 0.01) was protective of waitlist DDL. Conclusions: Female patients and those with good functional status experienced less waitlist DDL. Center procurement versatility through use of MP and LDLT in addition to SCS is also associated with decreased DDL.