Temporal trends in the etiologies of hepatocellular carcinoma and non-hepatocellular carcinoma associated liver transplants in the US in the last decade

Introduction: The trend in etiologies of liver disease in Liver transplant (LT) recipients with HCC (Hepatocellular carcinoma) and non-HCC has been changing in the US. This study evaluated these trends over the last 10 years using the national US LT database.
Methods: We studied adult patients in the UNOS database from 2015 to 2025 who received deceased donor liver transplants. We grouped them by the etiologies of liver disease using UNOS diagnostic codes: Hepatitis C (HCV), Alcohol-related (ALD), Metabolic Associated Steatotic Liver Disease (MASLD), Hepatitis B (HBV) and others. 
Results: Between 2015 and 2025, 23,307 HCC and 64,569 non-HCC liver transplant recipients were identified. Overall number and proportion of liver transplant recipients with HCC declined from 2015 to 2025 (Figure 1). Among HCC transplants, HCV declined markedly from 65.0% to 22.5%, while MASLD surpassed it as the leading etiology by 2025 (10.5% to 25.7%), and ALD increased from 8.8% to 21.16%. A parallel shift was observed in non-HCC transplants, where ALD has become the dominant indication (25.5% to 42.8%). HCV has declined from 23.2% to 5%, while MASLD remaining stable at around 16–19% (Figure 2).
Conclusion: The main indication for liver transplants in HCC patients has shifted from HCV to MASLD. This demonstrates the successful efforts to treat HCV nationally and hinder development/progression to cirrhosis and HCC in this patient population. It also highlights a growing need to aggressively surveillance for HCC in the MASLD and ALD populations.