Leveraging Frailty to Mitigate Sex-Based Disparities in Access to Liver Transplant: Justice in Allocation

For patients with end-stage liver disease (ESLD), liver transplant is the only life-saving therapy. Given the ongoing organ shortage, a Model for End-stage Liver Disease (MELD)–based allocation was introduced in 2002 to ensure that the sickest patients were offered transplant first. MELD is a calculation based on objective laboratory data, including serum creatinine level, associated with 90-day mortality among patients with ESLD. Despite the goal of defining an objective, equitable measure of disease severity, MELD-based allocation inadvertently introduced sex-based disparities in liver transplant, with women experiencing higher wait list mortality and lower likelihood of transplant compared with men.¹ These sex-based disparities may be the result of including serum creatinine level as a measure of renal dysfunction in MELD. Importantly, serum creatinine level has been demonstrated to vary significantly based on differences in muscle mass, and not surprisingly, women tend to have lower serum creatinine levels than men, despite having the same measured kidney function (measured glomerular filtration rate). Attempts to account for this biological difference in MELD-based allocation (eg, substituting measured glomerular filtration rate for serum creatinine level) have not been widely embraced, because they would require additional testing beyond simple blood draws and be difficult to update in real time.² The search for alternative measures that can be easily incorporated into existing allocation algorithms is greatly needed. Frailty may be the answer. It has been identified as a risk factor for wait list mortality and is associated with declining lean body mass.³