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

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. This was a retrospective cohort study of patients listed for LT between January 1, 2005, and December 12, 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). 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.