HCV NAT+ consent improves liver transplant and waitlist mortality in patients listed for HCC MELD exceptions

There is significant supply-demand mismatch in liver transplantation. Organs from hepatitis C virus (HCV) nucleic acid amplification test (NAT)+ donors have reduced time to transplant and waitlist mortality, however the impact of HCV listing on waitlist outcomes is unknown in patients listed with hepatocellular carcinoma (HCC) MELD exceptions. We conducted a retrospective cohort study using US transplant registry data. Patients listed for a single-organ liver transplant from 1/2016-10/2023 with active HCC MELD exceptions were included and categorized by HCV NAT+ listing status. Trends in NAT+ listing were explored across time and centers. Adjusted associations between NAT+ listing and transplantation or waitlist death were evaluated using competing risk models. Of the 15,852 patients listed for HCC MELD exceptions, 4,954 (31.3%) were listed for HCV NAT+ organs while 10,898 (68.7%) were not. The proportion of NAT+ listed patients increased from 21% (2016) to 56% (2023). There was substantial center-level variation in the proportion of HCV NAT+ listed patients. HCV NAT+ listing was associated with increased subhazard of transplantation (sHR 1.46, 95% CI 1.33-1.61, p <0.001) and decreased subhazard of waitlist mortality (sHR 0.82, 95% CI 0.68-0.99, p =0.038). The effect of HCV NAT+ listing on transplant likelihood was amplified after accounting for time-updated receipt of exception points at 6 months (csHR 11.4, 95% CI 9.15-14.1, p <0.001). HCV NAT+ listing has increased in HCC MELD exception patients, and listing is associated with increased transplantation and reduced mortality. Given substantial center-level variability in NAT+ listing, standardized efforts are needed to improve patient education and access to HCV NAT+ organs.