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

There is a significant supply-demand mismatch in liver transplantation. Organs from 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 HCC MELD exceptions. We conducted a retrospective cohort study using US transplant registry data. Patients listed for a single-organ liver transplant from January 2016 to October 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, 4954 (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.