To promote equitable organ distribution between HCC and high MELD patients, the MELD exception policy has undergone several iterations. The 2019 Median MELD at Transplant (MMaT) minus 3 points system has made exceptions more stringent, leading to fewer HCC points and longer waitlist times for deceased donor liver transplantation (DDLT) recipients. The impact of these changes on living donor liver transplantation (LDLT) utilization remains unknown.

Using United Network for Organ Sharing (UNOS) data, we identified adult HCC recipients of LDLT or DDLT across three eras: Pre-MMaT era 1 (2005–2015), Pre-MMaT era 2 (2015–2019), and the MMaT-3 era (2019–2021). Our primary outcome was changes in rates of LDLT for patients with HCC in the different MELD policy eras. Secondary outcomes included LDLT rates in the pre- and post-MMaT eras categorized by demographics. Interrupted time series, logistic regression, and Cox proportional hazards models evaluated transplantation trends, predictors of LDLT, and time from listing to transplant, respectively.

Among 22,994 recipients, LDLT rates significantly increased after MMaT-3 implementation ( p = 0.013), while DDLT rates declined ( p < 0.001). Public insurance (OR = 1.54, 95% CI: 1.07, 2.22) and residence in UNOS regions 3 and 4 (OR= 4.63, 95% CI: 1.66, 14.37, p < 0.001) were associated with increased odds of LDLT during the MMaT-3 era. Independent of era, female sex (OR = 1.717, 95% CI: 1.414, 2.078, p < 0.001) and higher education ( p < 0.001) predicted LDLT. LDLT recipients had shorter time to transplant overall (HR = 1.37, 95% CI: 1.23,1.53), and the gap in time to transplant between LDLT and DDLT recipients widened post-MMaT, with DDLT recipients waiting longer.

Evolving MELD exception policies may shift time to transplant and highlight the potential role of LDLT in mitigating waitlist mortality by providing increased access and shorter time to transplantation in HCC patients.