Trends in candidate HCV NAT+ listing and associated impacts on liver transplantation waitlist outcomes.

Abstract

Direct-acting antiviral agents have facilitated the utilization of hepatitis C virus (HCV)+ organs in HCV nucleic acid amplification test (NAT)- recipients. We evaluated trends in HCV NAT+ listing and impact on transplant probability, waitlist mortality, and likelihood of receiving HCV NAT+ organs using the United Network for Organ Sharing dataset of adult patients waitlisted for liver transplantation from 1/2016-9/2023. Multivariable regression models accounting for competing risks were fit to study waitlist outcomes. 21,776 patients were initially listed for HCV NAT+ organs while 45,378 were not. The percentage of waitlisted patients listed for these organs increased significantly from 2016 to 2023 (8.8% to 60.8%, p<0.001). Initial HCV NAT+ listing was associated with a waitlist mortality benefit in 2021-2023 (SHR 0.73, 95% CI 0.68-0.79, p<0.001) and 17% reduced hazard of overall mortality (HR 0.83, 95% CI 0.78-0.89, p<0.001). 16.0% of the total protective effect associated with HCV NAT+ listing on overall survival was mediated through actual receipt of HCV NAT+ organs (TERERI of -0.160 and a PIE of -0.026; p<0.001). Patients not listed for HCV NAT+ organs in the modern era are relatively disadvantaged in terms of waitlist outcomes. While listings have risen over time, there remains center-level and geographic variation.