Improved liver transplant outcomes for patients with hilar cholangiocarcinoma following implementation of the MMAT-3 policy.

Shaikh A, Lee TH, Lymberopoulos P, Benhammou JN, Rich N, Agopian VG, Hernaez R, Goss J, Singal AG, El-Serag HB, Rana A, Kanwal F, Berg C, Cholankeril G. Improved liver transplant outcomes for patients with hilar cholangiocarcinoma following implementation of the MMAT-3 policy. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society. 2025 Nov 6 DOI: 10.1097/LVT.0000000000000768.

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Abstract:

In 2019, the United Network for Organ Sharing (UNOS) policy for patients with hilar cholangiocarcinoma (hCCA) changed from granting a Model for End-Stage Liver Disease (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(10/01/15-11/15/2018) and the MMaT eras (05/15/2019-07/01/2022). We also compared these outcomes to those of propensity-matched hepatocellular carcinoma (HCC) patients. Our study demonstrated 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 three-year LT probability improved from 72.1% to 79.6% (p < 0.001). Furthermore, waitlist mortality also dropped, with three-year waitlist mortality decreasing from 26.6% to 17.6% (p = 0.04). Post-transplant survival remained unchanged in both eras. Compared to HCC patients, hCCA patients in the pre-MMaT era had lower LT probability (one-year:56.0 vs. 75.0%, three year:72.1 vs. 82.1% (p < 0.001)) and higher waitlist mortality (three-year dropout:26.6% vs. 13.1%,p < 0.001). Conversely, in the MMaT era, hCCA patients had similar LT probability to HCC patients. However, although significantly improved, waitlist mortality remained higher in hCCA patients compared to HCC patients (three-year dropout: 17.6% vs. 14.%, p = 0.02). Under the MMaT policy, hCCA patients have improved access to LT with improved waitlist survival.