Improved liver transplant outcomes for patients with hilar cholangiocarcinoma following implementation of the MMAT-3 policy

In 2019, the United Network for Organ Sharing (UNOS) policy for patients with hilar cholangiocarcinoma (hCCA) changed from granting a Model for End-Stage Liver Disease (MELD) exception score of 22 with 10% escalation every 3 months to a median MELD at transplant minus three (MMaT-3) without escalation, after completion of an approved neoadjuvant protocol. Using the UNOS registry, we compared waitlist and post-transplant outcomes in hCCA patients who received exception points in the pre-MMaT(10/01/15–11/15/2018) and the MMaT eras (05/15/2019–07/01/2022). We also compared these outcomes to those of propensity-matched hepatocellular carcinoma (HCC) patients. Our study demonstrated the probability of liver transplant (LT) significantly increased in hCCA patients during the MMaT era. One-year LT probability rose from 56.0% to 73.6% ( p <0.001), and three-year LT probability improved from 72.1% to 79.6% ( p <0.001). Furthermore, waitlist mortality also dropped, with three-year waitlist mortality decreasing from 26.6% to 17.6% ( p =0.04). Post-transplant survival remained unchanged in both eras. Compared to HCC patients, hCCA patients in the pre-MMaT era had lower LT probability (one-year:56.0 vs. 75.0%, three year:72.1 vs. 82.1% ( p <0.001)) and higher waitlist mortality (three-year dropout:26.6% vs. 13.1%, p <0.001). Conversely, in the MMaT era, hCCA patients had similar LT probability to HCC patients. However, although significantly improved, waitlist mortality remained higher in hCCA patients compared to HCC patients (three-year dropout: 17.6% vs. 14.%, p =0.02). Under the MMaT policy, hCCA patients have improved access to LT with improved waitlist survival.