Delisting for clinical improvement as a proxy for recompensated cirrhosis on the U.S. liver transplant waitlist: A retrospective cohort study

Background & Aims: Recompensation is emerging as a concrete outcome for patients with effective disease-modifying treatments for cirrhosis. Delisting due to clinical improvement (DCI) from the liver transplant (LT) waitlist may serve as a proxy for recompensation. This study investigated factors associated with time on the waitlist and risk of relisting. Approach & Results: This was a retrospective cohort study of patients listed for LT between 1/1/2005-12/31/2024 using the Organ Procurement and Transplantation Network (OPTN) database. Timing of DCI was categorized as: <1 year, 1-3 years, and ≥3 years. Of 127,168 patients, 6.9% achieved DCI. The proportion of patients experiencing DCI was highest for hepatitis B virus (9.9%), alcohol-associated liver disease (8.3%), and autoimmune hepatitis (8.2%). Median time to DCI was 2.5 years: 19% were delisted in <1 year, 39% in 1–3 years, and 42% in ≥ 3 years. Among patients waitlisted as Child-Turcotte-Pugh (CTP) class B or C, only 40.6% improved to CTP A at DCI. Relisting after DCI occurred in 9.6%, with 33% of these driven by hepatocellular carcinoma. In multivariable analysis, only patients with both MELD score improvement ≥3 points and CTP class improvement had significantly lower relisting risk after DCI (adjusted HR 0.52; p <0.001), but not those meeting either criterion individually. Additional relisting predictors included albumin <3.5 g/dL at DCI, male sex, and cirrhosis etiology (all p <0.001). Conclusions: The occurrence of DCI is variable across disease etiologies. Achieving combined improvement in MELD and CTP class may better identify durable clinical improvement and guide safe waitlist removal decisions.