Prioritizing Low-Risk HCC Patients for Liver Transplant May Worsen Waitlist Outcomes for Higher-Risk Candidates: Liver Transplantation | July 2026

Introduction:

Liver transplantation (LT) offers the greatest survival benefit for patients with hepatocellular carcinoma (HCC) at high risk of disease progression while awaiting transplant. However, current allocation policies provide similar transplant priority regardless of an individual patient's risk of waitlist dropout. This national U.S. study examined whether transplant centers that preferentially transplant low-dropout-risk (LDR) HCC patients influence access and outcomes for patients with higher clinical urgency.

Why was this study needed?

The survival benefit of liver transplantation differs substantially according to a patient's risk of waitlist dropout.

Current liver allocation policies provide similar priority to all eligible HCC patients.

The extent to which transplant centers preferentially transplant low-risk HCC patients has been poorly understood.

Center-level practices may unintentionally reduce transplant opportunities for higher-risk candidates.

Better understanding of these practices could help improve fairness and efficiency in organ allocation.

Results:

This national study analyzed 7,198 HCC transplant candidates across 93 U.S. liver transplant centers.

The proportion of low-dropout-risk HCC patients receiving liver transplantation varied markedly between centers, ranging from 0% to 42%.

Among standard-risk HCC candidates, listing at centers that frequently transplanted low-risk patients was associated with:

Lower likelihood of receiving a liver transplant.

Higher risk of waitlist dropout before transplantation.

In contrast, low-dropout-risk patients experienced similar outcomes regardless of transplant center, and post-transplant survival did not differ between center types.

These findings suggest that preferential transplantation of low-risk HCC patients may reduce organ availability for candidates with greater clinical urgency without improving overall post-transplant outcomes.

Clinical Impact:

This study raises important questions regarding equity in liver transplant allocation for HCC. Although low-risk patients achieve excellent outcomes, prioritizing them may inadvertently disadvantage patients at higher risk of tumor progression or liver-related deterioration. The findings support consideration of risk-adapted allocation strategies, where both tumor biology and likelihood of waitlist dropout are incorporated into transplant decision-making. Such an approach could maximize the overall survival benefit derived from scarce donor organs while promoting greater fairness across transplant programs.

Bottom Line:

Liver transplant centers that preferentially transplant low-dropout-risk HCC patients have poorer waitlist outcomes for higher-risk candidates without improving post-transplant survival. These findings support reevaluating HCC allocation strategies to better prioritize patients with the greatest risk of waitlist dropout and the highest potential survival benefit from transplantation.