Waitlist suspension is associated with persistent reduction in access to liver transplantation

Candidates awaiting liver transplantation may undergo waitlist suspension, the temporary inactivation of candidates from organ allocation, for various medical or logistical reasons. We performed a national cohort study using the United Kingdom Transplant Registry to evaluate the association between waitlist suspension and outcomes in adults listed for liver-only transplantation. Adjusted time-varying cause-specific Cox models, with start-stop times for suspension, were used as the primary analysis. Separate sensitivity analyses adjusted for center-specific effects, censoring for COVID-19-related suspensions, censoring clinical improvement suspensions, and incorporating a 30-day landmark removing early events from the risk set. Among 13 596 candidates, 3250 (23.9%) experienced at least 1 suspension episode. In adjusted time-varying analyses, reactivation following suspension was strongly associated with reduced access to transplantation (hazard ratio [HR], 0.36; 95% confidence interval [CI], 0.32-0.39, P < .001), but was not associated with increased death/delisting hazard (HR, 0.95; 95% CI, 0.84-1.08, P = .451), and currently suspended status showed no consistent association with death/delisting (HR, 1.11; 95% CI, 0.90-1.37, P = .310). Findings were robust across center-adjustment and sensitivity analyses. Waitlist suspension identifies a clinically important transition point after which transplant access remains reduced despite reactivation.