Liver transplant center prioritization of patients with low-dropout-risk hepatocellular carcinoma is associated with worse waitlist outcomes for remaining candidates

The survival benefit of liver transplantation (LT) for hepatocellular carcinoma (HCC) varies by waitlist dropout risk, yet allocation policy applies uniform prioritization, and center practices remain poorly characterized. We performed a retrospective cohort study using the United Network for Organ Sharing database, including LT candidates with HCC between February 4, 2020, and October 1, 2024. Low-dropout-risk (LDR) HCC was defined as MELD<15, Child–Pugh A, single lesion <3 cm, and AFP≤20 ng/mL at listing; all others were standard risk. Centers were classified as low-LDR (lowest quartile) or high-LDR (highest quartile) based on the proportion of their transplants that were LDR candidates with complete radiographic response (no viable tumor) on the last pre-LT imaging. Waitlist outcomes were analyzed with adjusted Fine–Gray competing-risk models. Among 7198 candidates across 93 centers, the proportion of LDR transplants varied widely across centers (range 0%–42%). In adjusted analyses, among standard-risk candidates, listing at a high-LDR rather than low-LDR center was associated with lower transplantation (SHR 0.81, 95% CI 0.72–0.90) and higher dropout (SHR 1.39, 95% CI 1.14–1.70) (both p <0.001). Waitlist outcomes for LDR candidates and post-transplant survival did not differ by center type. These findings suggest substantial center variation exists for LDR HCC and may disadvantage access among higher-need candidates despite similar post-transplant survival.