REPRIORITIZING THE LIVER TRANSPLANT WAITING LIST: IMPACT OF AUTOMATIC MELD-NA 29 FOR REFRACTORY ASCITES

Introduction and Objectives

In Brazil, liver allocation follows the MELD-Na score. To address high-risk conditions not reflected by high scores, special situations are evaluated individually. Refractory ascites and hepatocellular carcinoma (HCC) account for ∼80% of such cases. In 2021, Technical Note No. 32/2021 granted 29 MELD-Na points to patients with refractory ascites to improve access to liver transplant (LT).

Primary, to compare the time from special situation approval to LT in cases of refractory ascites and HCC, before and after the new policy. Secondary, assess transplant volume and waiting list mortality in both groups.

Patients and Methods

Retrospective, single-center study including adult patients granted special situation for refractory ascites or HCC in 2018–2020 (pre-policy) and 2022–2024 (post-policy). Cases from 2021 were excluded. Outcomes were time to LT, mortality on the waiting list, and transplant numbers.

Results

In refractory ascites, median time to LT decreased by 95 days (186 to 91; −51.1%). In HCC, waiting time increased by 36 days (197 to 233; +18.3%). Waiting list mortality dropped in both groups: from 16% to 7% for refractory ascites and from 11% to 6% for HCC. The absolute number of transplants remained stable across periods.

Conclusions

Technical Note 32/2021 had a direct positive impact on patients with refractory ascites. However, it was associated with increased waiting time for HCC patients, although without increased mortality. These findings highlight the need for continuous monitoring of allocation policies and broader multicenter evaluation.

Conflict of interest: None