Trends in candidate hepatitis C virus nucleic acid amplification test (NAT)+ listing and associated impacts on liver transplantation waitlist outcomes.

Direct-acting antiviral agents have facilitated the utilization of hepatitis C virus (HCV)+ organs in HCV nucleic acid amplification test (NAT)- recipients. We evaluated trends in HCV NAT+ listing and its impact on transplant probability, waitlist mortality, and likelihood of receiving HCV NAT+ organs using the United Network for Organ Sharing data set of adult patients waitlisted for liver transplantation from January 2016 to September 2023. Multivariable regression models accounting for competing risks were fit to study waitlist outcomes. Initially, 21 776 patients were listed for HCV NAT+ organs whereas 45 378 were not. The percentage of waitlisted patients listed for these organs increased significantly from 2016 to 2023 (8.8% to 60.8%, P < .001). Initial HCV NAT+ listing was associated with a waitlist mortality benefit in 2021-2023 (subhazard ratio 0.73, 95% CI 0.68-0.79, P < .001) and 17% reduced hazard of overall mortality (hazard ratio 0.83, 95% CI 0.78-0.89, P < .001). Sixteen percent of the total protective effect associated with HCV NAT+ listing on overall survival was mediated through actual receipt of HCV NAT+ organs (total excess relative risk of -0.160 and a pure indirect effect of -0.026; P < .001). Patients not listed for HCV NAT+ organs in the modern era are relatively disadvantaged in terms of waitlist outcomes. Although listings have risen over time, there remains center-level and geographic variation.