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Original Investigation
May 20, 2020

Quantifying Sex-Based Disparities in Liver Allocation

Author Affiliations
  • 1Division of Transplantation, Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham
  • 2Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 3Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora
  • 4Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 5Division of Renal and Electrolytes, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 6Division of Transplantation, Department of Surgery, University of California School of Medicine, San Francisco, San Francisco
JAMA Surg. Published online May 20, 2020. doi:10.1001/jamasurg.2020.1129
Key Points

Question  What proportion of sex-based disparities in liver allocation is associated with geographic location, candidate anthropometric and liver measurements, or Model for End-stage Liver Disease score?

Findings  In this cohort study of 81 357 participants, women were 8.6% more likely to die while waiting for a liver transplant and were 14.4% less likely to receive a deceased donor liver transplant compared with men. Candidate anthropometric and liver measurements and creatinine level had stronger associations than geographic location with sex disparities in wait list mortality and the likelihood of deceased donor liver transplant.

Meaning  The findings suggest that mitigating sex-based disparities in liver allocation may require a comprehensive approach that extends beyond geographic factors currently being considered in the transplant community.

Abstract

Importance  Differences in local organ supply and demand have introduced geographic inequities in the Model for End-stage Liver Disease (MELD) score–based liver allocation system, prompting national debate and patient-initiated lawsuits. No study to our knowledge has quantified the sex disparities in allocation associated with clinical vs geographic characteristics.

Objective  To estimate the proportion of sex disparity in wait list mortality and deceased donor liver transplant (DDLT) associated with clinical and geographic characteristics.

Design, Setting, and Participants  This retrospective cohort study used adult (age ≥18 years) liver-only transplant listings reported to the Organ Procurement and Transplantation Network from June 18, 2013, through March 1, 2018.

Exposure  Liver transplant waiting list.

Main Outcomes and Measures  Primary outcomes included wait list mortality and DDLT. Multivariate Cox proportional hazards regression models were constructed, and inverse odds ratio weighting was used to estimate the proportion of disparity across geographic location, MELD score, and candidate anthropometric and liver measurements.

Results  Among 81 357 adults wait-listed for liver transplant only, 36.1% were women (mean [SD] age, 54.7 [11.3] years; interquartile range, 49.0-63.0 years) and 63.9% were men (mean [SD] age, 55.7 [10.1] years; interquartile range, 51.0-63.0 years). Compared with men, women were 8.6% more likely to die while on the waiting list (adjusted hazard ratio [aHR], 1.11; 95% CI, 1.04-1.18) and were 14.4% less likely to receive a DDLT (aHR, 0.86; 95% CI, 0.84-0.88). In the geographic domain, organ procurement organization was the only variable that was significantly associated with increased disparity between female sex and wait list mortality (22.1% increase; aHR, 1.22; 95% CI, 1.09-1.30); no measure of the geographic domain was associated with DDLT. Laboratory and allocation MELD scores were associated with increases in disparities in wait list mortality: 1.14 (95% CI, 1.09-1.19; 50.1% increase among women) and DDLT: 0.87 (95% CI, 0.86-0.88; 10.3% increase among women). Candidate anthropometric and liver measurements had the strongest association with disparities between men and women in wait list mortality (125.8% increase among women) and DDLT (49.0% increase among women).

Conclusions and Relevance  Our findings suggest that addressing geographic disparities alone may not mitigate sex-based disparities, which were associated with the inability of the MELD score to accurately estimate disease severity in women and to account for candidate anthropometric and liver measurements in this study.

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