Receipt of a pediatric liver offer as the first offer reduces waitlist mortality for adult women

Abstract

In liver transplantation, adults with small stature have a greater susceptibility to waitlist mortality. This may explain the persistent waitlist mortality disparity that exists for women. We hypothesized that women who receive early offers of pediatric donor livers have improved waitlist survival, and that preferentially offering these organs to women mitigates this sex-based disparity. We analyzed donor liver offers from 2010 to 2014. Adult candidates who received a first offer that ranked within the first three match run positions from the donors' perspective were classified based on gender and whether they received a pediatric versus adult offer. We used competing risks regression to associate first offer type and waitlist mortality. A total of 8,101 waitlist candidates received a first offer that was ranked within the first three match run positions: 5.6% (293/5,202) men and 6.2% (179/2,899) women received a pediatric donor liver as their first offer. In multivariable analyses, compared with adult-first men, adult-first women (subhazard ratio [sHR] 1.33, 95% confidence interval 1.17-1.51, P < 0.01) had an increased pretransplant mortality risk while pediatric-first men and pediatric-first women had noninferior risks of morality. Pediatric-to-adult and adult-to-adult recipients had similar risks of graft failure and posttransplant mortality.

Conclusion: Our study examines allograft selection by donor age, recipient sex, and in effect size as a means to address disparities in waitlist mortality. We found that women who received a pediatric donor liver as the first offer had a lower risk of waitlist mortality compared with those who receive adult offers. Our data provides a simple approach to mitigating the increased waitlist mortality experienced by women by incorporating donor and recipient size as variables into organ allocation. (Hepatology 2018).

FIG. 1.

Differences in eLV ratios between donors and recipients at first offer and offer acceptance. *Bars represent twenty-fifth and seventy-fifth percentile values, circles represent median eLV ratio at first offer, and diamonds represent median eLV at first offer acceptance. Greater than 1 indicates donor liver volume was estimated to be larger than recipient; less than 1 indicates vice-versa.

FIG. 2.

Waitlist mortality subhazard ratios among adult-first and pedi-first cohorts. Adult-first women have higher risks of pretransplant mortality compared with adult-first men, while pedi-first women do not. *Bars represent 95% CI, circles represent subhazard ratios for univariable analyses, diamonds represent subhazard ratios for multivariable analyses.