Disparities In Liver Transplantation Research Articles

Tall, Male, and What Else? Disparities in Liver Transplantation Based On Gender and Height.

Tall, Male, and What Else? Disparities in Liver Transplantation Based On Gender and Height.

Multiple listings as a reflection of geographic disparity in liver transplantation.

Geographic disparity in access to liver transplantation (LT) exists. This study sought to examine Model for End-Stage Liver Disease-era multiply listed (ML) LT candidate (ie, candidates who list at 2 or more LT centers to receive a liver transplant). Data on adult, primary, non-status 1 LT candidates (n= 59,557) listed from January 1, 2005 to December 31, 2011 were extracted from the United Network for Organ Sharing's Standard Transplant Analysis and Research files. Comparisons of ML vs singly listed LT candidates were performed, with additional analysis performed at the donor service area (DSA) and regional level, as well as assessment of the donor population used. There were 1,358 (2.3%) ML candidates during the 7-year study period. Multiply listed candidates compared with singly listed candidates were more often male, white, blood type O, nondiabetic, college educated, and privately insured. The odds of pursuing ML increased considerably as time on the waitlist increased. Of the ML candidates, 918 (67.6%) went on to receive a liver transplant (ML-LT), 767 (83.6%) at the secondary listing DSA, which was a median of 588 miles (range 229 to 1095 miles) from the primary listing DSA. When compared with the primary listing DSA, the secondary listing DSA had significantly lower match Model for End-Stage Liver Disease scores, as well as shorter wait times. Regional analysis demonstrated significantly higher odds for pursuing ML from LT candidates located within regions 1, 5, and9. A small and distinctive cohort of LT candidates pursue ML, indicating willingness and means to travel to receive a liver transplant. Efforts toward equalizing LT access across regional disparities are warranted, and can help obviate the need for ML.

Disparities in liver transplantation: the association between donor quality and recipient race/ethnicity and sex.

We aimed to examine the association between recipient race/ethnicity and sex, donor liver quality, and liver transplant graft survival. Adult non-status 1 liver recipients transplanted between March 1, 2002, and December 31, 2008, were identified using Scientific Registry of Transplant Recipients data. The factors of interest were recipient race/ethnicity and sex. Donor risk index (DRI) was used as a donor quality measure. Logistic regression was used to assess the association between race/ethnicity and sex in relation to the transplantation of low-quality (high DRI) or high-quality (low DRI) livers. Cox regression was used to assess the association between race/ethnicity and sex and liver graft failure risk, accounting for DRI. Hispanics were 21% more likely to receive low-quality grafts compared to whites (odds ratio [OR]=1.21, P=0.002). Women had greater odds of receiving a low-quality graft compared to men (OR=1.24, P<0.0001). Despite adjustment for donor quality, African American recipients still had higher graft failure rates compared to whites (hazard ratio [HR]=1.28, P<0.001). Hispanics (HR=0.89, P=0.023) had significantly lower graft failure rates compared to whites despite higher odds of receiving a higher DRI graft. Using an interaction model of DRI and race/ethnicity, we found that the impact of DRI on graft failure rates was significantly reduced for African Americans compared to whites (P=0.02). This study shows that while liver graft quality differed significantly by recipient race/ethnicity and sex, donor selection practices do not seem to be the dominant factor responsible for worse liver transplant outcomes for minority recipients.

Addressing Geographic Disparities in Liver Transplantation Through Redistricting

Severe geographic disparities exist in liver transplantation; for patients with comparable disease severity, 90-day transplant rates range from 18% to 86% and death rates range from 14% to 82% across donation service areas (DSAs). Broader sharing has been proposed to resolve geographic inequity; however, we hypothesized that the efficacy of broader sharing depends on the geographic partitions used. To determine the potential impact of redistricting on geographic disparity in disease severity at transplantation, we combined existing DSAs into novel regions using mathematical redistricting optimization. Optimized maps and current maps were evaluated using the Liver Simulated Allocation Model. Primary analysis was based on 6700 deceased donors, 28 063 liver transplant candidates, and 242 727 Model of End-Stage Liver Disease (MELD) changes in 2010. Fully regional sharing within the current regional map would paradoxically worsen geographic disparity (variance in MELD at transplantation increases from 11.2 to 13.5, p = 0.021), although it would decrease waitlist deaths (from 1368 to 1329, p = 0.002). In contrast, regional sharing within an optimized map would significantly reduce geographic disparity (to 7.0, p = 0.002) while achieving a larger decrease in waitlist deaths (to 1307, p = 0.002). Redistricting optimization, but not broader sharing alone, would reduce geographic disparity in allocation of livers for transplant across the United States.

Living-related Liver Transplantation in Diego Blood Group Disparity: A Case Report

To date, only limited cases of Diego blood group disparity in liver transplantation have been reported, and no cases with a long-term clinical course have been documented. Herein, we report a case of Diego blood group disparity in liver transplantation with details of long-term follow-up. The recipient was a 47-year-old woman with primary biliary cirrhosis; her 18-year-old daughter was the donor. Both recipient and donor were of blood type O according to the ABO blood group system. Preoperative serological tests showed the presence of antibodies against the Dia antigen only in the recipient, and not in the donor. Thus, the Diego phenotype was Di(a+) in the donor and Di(a−) in the recipient. Living-related liver transplantation was performed in July 2009. Immediate graft function was obtained, and no signs of humoral or cellular rejection were observed during the postoperative period. Further, anti-Dia antibodies were not detected throughout the postoperative course. The patient is alive and shows no signs of humoral rejection 34 months after liver transplantation. Liver transplantation has been performed successfully in cases of Diego blood group disparity.

Impact of estimated liver volume and liver weight on gender disparity in liver transplantation.

Although lower Model for End-Stage Liver Disease (MELD) scores due to lower levels of serum creatinine in women might account for some of the gender disparity in liver transplantation (LT) rates, even within MELD scores, women undergo transplantation at lower rates than men. It is unclear what causes this disparity, but transplant candidate/donor liver size mismatch may be a factor. We analyzed Organ Procurement and Transplantation Network data for patients with end-stage liver disease on the waiting list. A pooled conditional logistic regression analysis was used to assess the association between gender and LT and to determine the degree to which this association was explained by lower MELD scores or liver size. In all, 28,866 patients and 424,001 person-months were included in the analysis. The median estimated liver volume (eLV) and the median estimated liver weight (eLW) were significantly lower for women versus men on the LT waiting list (P < 0.001). When we controlled for the region and the blood type, women were 25% less likely to undergo LT in a given month in comparison with men (P < 0.001). When the MELD score was included in the model, the odds ratio (OR) for gender increased to 0.84, and this suggested that 9 percentage points of the 25% gender disparity were due to the MELD score. When eLV was added to the model, there was an additional 3% increase in the OR for gender, and this suggested that transplant candidate/donor liver size mismatch was an underlying factor for the lower LT rates in women versus men (OR = 0.87, P < 0.001). In conclusion, lower LT rates among women on the waiting list can be explained in part by lower MELD scores, eLVs, and eLWs in comparison with men. However, at least half of the gender disparity still remains unexplained.

Organizations and Researchers Strive to Address Disparities in Cancer Care

Organizations and Researchers Strive to Address Disparities in Cancer Care

Persistent disparities in liver transplantation for patients with hepatocellular carcinoma in the United States, 1998 through 2007

Prior studies have demonstrated that among patients with hepatocellular carcinoma (HCC), African Americans (AAs) and Asian/Pacific Islanders (APIs) are substantially less likely to undergo liver transplantation (LT) compared with whites. The authors examined whether disparities in the receipt of LT among LT-eligible HCC patients changed over a 10-year time period, and whether the disparities might be explained by sociodemographic or clinical factors. The National Cancer Data Base, a national hospital-based cancer registry, was used to study 7707 adults with small (≤ 5 cm), nonmetastatic HCC diagnosed between 1998 and 2007. Racial/ethnic patterns in the use of LT were compared during 2 periods of 5 years each: 1998 through 2002 (n = 2412 patients) and 2003 through 2007 (n = 5295 patients). Data regarding comorbid medical conditions were only available during the later time period. Large and persistent racial/ethnic differences in the probability of receiving LT were observed. Compared with whites, hazard ratios (HRs) and associated 95% confidence intervals (95% CIs) for receiving LT from 1998 through 2002 were 0.64 (95% CI, 0.46-0.89) for AA patients, 1.01 (95% CI, 0.79-1.29) for Hispanic patients, and 0.52 (95% CI, 0.39-0.68) for API patients. Analogous results for 2003 through 2007 were 0.64 (95% CI, 0.54-0.76) for AA patients, 0.86 (95% CI, 0.75-0.99) for Hispanic patients, and 0.58 (95% CI, 0.49-0.69) for API patients. AA patients were less likely than whites to undergo any form of surgery, and API patients were more likely than whites to undergo surgical resection. Adjustment for sociodemographic and clinical factors produced only small changes in these HRs. Between 1998 and 2007, there were large and persistent racial/ethnic disparities noted in the receipt of LT among patients with HCC. These disparities were not explained by sociodemographic or clinical factors.

Geographic Variation in Organ Availability Is Responsible for Disparities in Liver Transplantation between Hispanics and Caucasians

The aims of this study were to determine whether disparities in waiting list outcomes exist for Hispanics and African Americans during the post-MELD era, and to investigate interactions between disparities and geography. Scientific Registry of Transplant Recipients data were used to compare Hispanics and African Americans to Caucasians listed between 2003 and 2008. Endpoints included (i) receipt of a liver transplant and (ii) death or removal from the waiting list for being too sick or medically unsuitable. Adjustment for possible confounders was performed using multivariate Cox regression, with adjustment for geographic variation using a fixed-effects multilevel model. In multivariate analysis, African Americans have similar hazard of transplantation and death/removal as Caucasians during the post-MELD era. However, Hispanics are less likely to receive a transplant than Caucasians despite adjustment for potential confounders (HR 0.80, 95% CI 0.77-0.83), while having a similar hazard of death/removal. This effect disappeared after adjusting for unequal regional distribution of Hispanics, who represent 8% of patients in donation service areas (DSAs) having median waiting times of < or = 155 days versus 19% in DSAs with median waiting times of >155 days. In conclusion, disparities in liver transplantation exist for Hispanics during the post-MELD era, caused by geographic variation in organ availability.

Racial disparities in liver transplantation for hepatitis B: To be or not to be

Racial disparities in liver transplantation for hepatitis B: To be or not to be

Disparities in liver transplantation in the post–model for end-stage liver disease era: Are we there yet? #

Disparities in liver transplantation in the post–model for end-stage liver disease era: Are we there yet? #

Disparities in Liver Transplantation Before and After Introduction of the MELD Score

Disparities in Liver Transplantation Before and After Introduction of the MELD Score

Disparities in Liver Transplantation Before and After Introduction of the MELD Score

Disparities in Liver Transplantation Before and After Introduction of the MELD Score

Disparities in Liver Transplantation Before and After Introduction of the MELD Score

Disparities in Liver Transplantation Before and After Introduction of the MELD Score

Liver Transplantation Allocation System Shows Improvement in Racial, But Not Gender, Disparities

After the introduction of a new system in 2002 to determine the allocation of donated livers, African-American patients are no longer less likely to receive a liver transplant, but disparities for women remain, according to a study in the November 26, 2008 issue of JAMA. The Model for End-Stage Liver Disease (MELD) score has been used by the Organ Procurement and Transplantation Network since February 2002 as the basis for allocation of deceased donor livers for transplantation among adults in the United States. The MELD score predicts the risk of death within 3 months and is based on objective laboratory variables: bilirubin, creatinine, and a ratio for the prothrombin time. “In the current system, patients with higher MELD scores receive greater priority for organ allocation regardless of the amount of time spent on the waiting list,” the authors write. Dr Cynthia A. Moylan of the Duke University Medical Center and colleagues used a national database to determine whether racial or gender-based disparities exist in access to liver transplantation since the MELD system has been implemented. The study included adult African-American and white patients registered on the United Network for Organ Sharing liver transplantation waiting list between January 1996 and December 2000 (pre-MELD group; n = 21,895) and between February 2002 and March 2006 (post-MELD group; n = 23,793). African-American patients, compared with white patients, were younger (average age, 49.2 vs 52.4 years) and more ill (MELD score at listing: median [midpoint], 16 vs 14). Analyses indicated that the odds of death or becoming too ill for liver transplantation within 3 years of listing were higher among African-American verus white patients in the pre-MELD cohort (27.0% vs 21.7%), but not in the post-MELD group (26.5% vs. 22.0%). The researchers also found that African-American patients were less likely than white patients to receive liver transplantation within 3 years of listing in the pre-MELD cohort, but not in the post-MELD cohort. “This elimination in racial disparity in the post-MELD cohort likely reflects the fact that the MELD score now accounts for the severity of a patient's disease when listed,” the authors write. By contrast, gender was significantly associated with death and liver transplantation after adjusting for race, despite the use of the MELD score. Women were more likely to die or become too ill for liver transplantation within 3 years of listing in the post-MELD group (23.7% of women vs 21.4% of men) but not in the pre-MELD group (22.4% of women vs 21.9% of men). Women were also less likely to receive a liver transplant within 3 years of listing in both the pre-MELD and post-MELD groups. “Sex differences persist despite the use of MELD. Whether these differences result from true anatomic differences or represent a problem not addressed by the use of the MELD score mandates further investigation,” the report states. “The use of the MELD score allocation system appears to have reduced at least racial disparity in liver transplantation. We hope that ongoing investigations and refinements of MELD can provide even greater equity in the allocation of this precious resource.” “The MELD system has helped decrease disparities regarding the allocation of donated livers, writes Dr David A. Axelrod of the Dartmouth-Hitchcock Medical Center and Dr. Elizabeth A. Pomfret of the Lahey Clinic Medical Center, in an accompanying editorial. “When compared with the system before 2002, the current MELD system is clearly a step toward achieving the goal of an equitable, efficient, and transparent organ allocation system. The MELD system appears to have reduced, but likely not eliminated, differential access based on race and ethnicity. However, modest differences based on sex persist, but could be addressed by revisions in the organ allocation policy to ensure that MELD scores are comparable across sexes.” “The sex disparity is likely a reflection of several factors, including a limitation in the MELD calculation, body and organ size considerations, and potentially differences in the etiology of the underlying liver disease.” See “Disparities in Liver Transplantation Before and After Introduction of the MELD Score,” JAMA. 2008;300:2371–2378.

Race and Sex Disparities in Liver Transplantation

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Disparities in Liver Transplantation Before and After Introduction of the MELD Score

In February 2002, the allocation system for liver transplantation became based on the Model for End-Stage Liver Disease (MELD) score. Before MELD, black patients were more likely to die or become too sick to undergo liver transplantation compared with white patients. Little information exists regarding sex and access to liver transplantation. To determine the association between race, sex, and liver transplantation following introduction of the MELD system. A retrospective cohort of black and white patients (> or = 18 years) registered on the United Network for Organ Sharing liver transplantation waiting list between January 1, 1996, and December 31, 2000 (pre-MELD cohort, n = 21 895) and between February 28, 2002, and March 31, 2006 (post-MELD cohort, n = 23 793). Association between race, sex, and receipt of a liver transplant. Separate multivariable analyses evaluated cohorts within each period to identify predictors of time to death and the odds of dying or receiving liver transplantation within 3 years of listing. Patients with hepatocellular carcinoma were analyzed separately. Black patients were younger (mean [SD], 49.2 [10.7] vs 52.4 [9.2] years; P < .001) and sicker (MELD score at listing: median [interquartile range], 16 [12-22] vs 14 [11-19]; P < .001) than white patients on the waiting list for both periods. In the pre-MELD cohort, black patients were more likely to die or become too sick for liver transplantation than white patients (27.0% vs 21.7%) within 3 years of registering on the waiting list (odds ratio [OR], 1.51; 95% confidence interval (CI), 1.15-1.98; P = .003). In the post-MELD cohort, black race was no longer associated with increased likelihood of death or becoming too sick for liver transplantation (26.5% vs 22.0%, respectively; OR, 0.96; 95% CI, 0.74-1.26; P = .76). Black patients were also less likely to receive a liver transplant than white patients within 3 years of registering on the waiting list pre-MELD (61.6% vs 66.9%; OR, 0.75; 95% CI, 0.59-0.97; P = .03), whereas post-MELD, race was no longer significantly associated with receipt of a liver transplant (47.5% vs 45.5%, respectively; OR, 1.04; 95% CI, 0.84-1.28; P = .75). Women were more likely than men to die or become too sick for liver transplantation post-MELD (23.7% vs 21.4%; OR, 1.30; 95% CI, 1.08-1.47; P = .003) vs pre-MELD (22.4% vs 21.9%; OR, 1.08; 95% CI, 0.91-1.26; P = .37). Similarly, women were less likely than men to receive a liver transplant within 3 years both pre-MELD (64.8% vs 67.6%; OR, 0.80; 95% CI, 0.70-0.92; P = .002) and post-MELD (39.9% vs 48.7%; OR, 0.70; 95% CI, 0.62-0.79; P < .001). Following introduction of the MELD score to the liver transplantation allocation system, race was no longer associated with receipt of a liver transplant or death on the waiting list, but disparities based on sex remain.

Decreasing disparity in liver transplantation among white and Asian patients with hepatocellular carcinoma

A preliminary study using national cancer surveillance data from 1998 through 2002 suggested that there were significant differences between non-Hispanic whites ('whites') and Asian/Pacific Islanders (APIs) in the use of liver transplantation as a treatment for hepatocellular carcinoma (HCC). The objective of the current study was to examine whether differences in liver transplantation between whites and APIs with HCC were changing over time. By using a population-based, statewide cancer registry, data were obtained on all HCC cases diagnosed in California between 1998 and 2005, and the study was limited to white and API patients with nonmetastatic HCC who had tumors that measured < or = 5 cm in greatest dimension (n = 1728 patients). From 1998 through 2003 (n = 1051 patients), the odds of undergoing liver transplantation were 2.56 times greater for white patients than for API patients (95% confidence interval [CI], 1.72-3.80 times higher), even after adjusting for age, sex, marital status, year of diagnosis, TNM stage, and tumor grade. In contrast, during 2004 and 2005 (n = 677 patients), there were no significant differences in the odds of undergoing liver transplantation. Between 2002 and 2004, changes in liver transplantation policy assigned priority points to patients with HCC (initially to stage I and II, then to stage II only). After the policy changes, API patients with HCC experienced a significant increase in stage II diagnoses, whereas white patients did not. In California, there was a large and significant disparity in the rate of liver transplantation among white and API patients with HCC from 1998 through 2003 but not during 2004 and 2005. Changes in liver transplantation policy from 2002 through 2004 may have played a role in decreasing this difference.

Racial/Ethnic Disparities in Liver Transplant Surgery and Hospice Use: Parallels, Differences, and Unanswered Questions

Despite well-documented racial/ethnic disparities in liver transplantation and hospice enrollment, reasons for these disparities are unclear. This study was conducted to elucidate what is known and unknown about the underlying causes of racial/ethnic disparities in liver transplantation and hospice enrollment. The root causes of inequities in access to liver transplantation and hospice are as yet poorly understood. Potential contributors to differences include differences in preferences, mistrust of the health care system, geographic factors such as neighborhood, health care system factors such as access to care and managed care versus fee-for-service insurance status, and social factors such as the availability of a full time caregiver. Although the goals of care are different, by examining hospice and transplant surgery side by side in the larger context of health disparities, a number of potentially promising avenues for future research have been uncovered.

Disparities in Liver Transplantation for Localized Hepatocellular Carcinoma: Race or Socioeconomic Class

Disparities in Liver Transplantation for Localized Hepatocellular Carcinoma: Race or Socioeconomic Class?