Changing Map of Liver Transplantation for HCC Following Implementation of New Acuity Circle Allocation System – Efforts to Overcome Disparities by Creating a New One

Introduction: The introduction of acuity circles-based allocation and change in the model for end-stage liver disease (MELD) exception points for hepatocellular carcinoma (HCC) has created a difference in transplant opportunity for hepatocellular carcinoma (HCC) patients. Methods: Characteristics of HCC and non-HCC orthotopic liver transplants (OLT) in the year before (2/2019-2/2020) and after (3/2020-2/2021) introduction of the acuity circle policy were assessed using the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) database. Results: Total OLTs reduced from 6699 in the pre-acuity circle era to 6660 in the post-acuity circle era (-0.6%); the decrease entirely driven by a decrease in HCC transplant (1529 to 1351; -11.6%). Six out of 11 regions had a reduction in the absolute number and percentage of HCC transplants with significant reductions in regions 2 (-37.8%, p<0.001) and 4 (-28.3%, p=0.001). More HCC patients were transplanted from low donation areas. We revealed a change in the map of organ sharing, with expansion from high- to low-MELD regions. Conclusions: While circles are meant to decrease disparities, HCC patients are disadvantaged based on geography, receiving different MELD scores based on geography despite having the same disease. The ongoing investigation of these trends is needed to ensure that HCC patients are not disparately disadvantaged due to their location.