Center-level variations are associated with disparate waitlist mortality and probability of liver transplant in MELD 35 and greater patients.

Liver transplant (LT) centers may have variations in their approach to high-acuity (MELD ≥35) candidates for listing and transplantation. We investigated center-specific differences in waitlist outcomes, probability of LT, and post-LT survival in MELD ≥35 patients. Adult candidates of LT (MELD ≥35) were identified from the Scientific Registry of Transplant Recipients between January 1, 2010, and April 1, 2022. Waitlist mortality was modeled with the center as a random effect. Centers were grouped based on the random effect coefficient, with the highest tertile representing the highest risk group (comprises centers with the highest risk of waitlist mortality attributable to the center). Cumulative incidence of death/delisting, probability of LT, and 1-year post-LT survival were compared, with patients stratified by a listing MELD ≥35 or increase to MELD ≥35 after listing. In patients who increased to MELD ≥35, the 1-year cumulative incidence of death/delisting was highest (50%) and the probability of transplant lowest (46%) in the high-risk group, compared to the low-risk group (37% and 55%, p <0.001 for both comparisons). For patients receiving an LT, post-transplant survival did not differ among the groups, though high-risk centers transplanted far less high-acuity patients. These variations may indicate that certain centers are associated with substantially decreased waitlist mortality for the highest acuity patients without corresponding decreases in post-transplant survival.