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 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 (October 1, 2015-November 15, 2018) and the MMaT eras (May 15, 2019-July 1, 2022). We also compared these outcomes to those of propensity-matched HCC patients. Our study demonstrated that 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 3-year LT probability improved from 72.1% to 79.6% ( p <0.001). Furthermore, waitlist mortality also dropped, with 3-year waitlist mortality decreasing from 26.6% to 17.6% ( p =0.04). Post-transplant survival remained unchanged in both eras. Compared with HCC patients, hCCA patients in the pre-MMaT era had lower LT probability (1-year: 56.0% vs. 75.0%, 3-year: 72.1% vs. 82.1%; p <0.001) and higher waitlist mortality (3-year dropout: 26.6% vs. 13.1%; p <0.001). Conversely, in the MMaT era, hCCA patients had a similar LT probability to HCC patients. However, although significantly improved, waitlist mortality remained higher in hCCA patients compared with HCC patients (3-year dropout: 17.6% vs. 14.%; p =0.02). Under the MMaT policy, hCCA patients have improved access to LT with improved waitlist survival.