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Comparative Study
. 2020 Jul 1;155(7):e201129.
doi: 10.1001/jamasurg.2020.1129. Epub 2020 Jul 15.

Quantifying Sex-Based Disparities in Liver Allocation

Jayme E Locke  1 , Brittany A Shelton  1 , Kim M Olthoff  2 , Elizabeth A Pomfret  3 , Kimberly A Forde  4 , Deirdre Sawinski  5 , Meagan Gray  1 , Nancy L Ascher  6
Affiliations
Comparative Study

Quantifying Sex-Based Disparities in Liver Allocation

Jayme E Locke et al. JAMA Surg. .

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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Conflict of interest statement

Conflict of Interest Disclosures: Dr Locke reported receiving personal fees from Sanofi and Hansa Medical outside the submitted work. Dr Sawinski reported serving on the external advisory boards of CareDx, Natera, and Veloxis outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Change in Excess Risk of Wait List Mortality Among Candidates for Liver Transplant Across Geographic Factors, Model for End-stage Liver Disease (MELD) Score, and Candidate Anthropometric and Liver Measurements
Adjusted hazard ratio (HR) of 1.00 indicates statistically equal likelihood of wait list mortality for men and women.
Figure 2.
Figure 2.. Change in Disparity in Likelihood of Deceased Donor Liver Transplant (DDLT) Among Liver Transplant Candidates Across Geographic Factors, Model for End-stage Liver Disease (MELD) Score, and Candidate Anthropometric and Liver Measurements
HR indicates hazard ratio.
See this image and copyright information in PMC

Comment in

References

    1. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000;31(4):864-871. doi:10.1053/he.2000.5852 - DOI - PubMed
    1. Wiesner R, Edwards E, Freeman R, et al. ; United Network for Organ Sharing Liver Disease Severity Score Committee . Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology. 2003;124(1):91-96. doi:10.1053/gast.2003.50016 - DOI - PubMed
    1. Croome KP, Lee DD, Burns JM, Keaveny AP, Taner CB. Intraregional model for end-stage liver disease score variation in liver transplantation: disparity in our own backyard. Liver Transpl. 2018;24(4):488-496. doi:10.1002/lt.25021 - DOI - PubMed
    1. Dzebisashvili N, Massie AB, Lentine KL, et al. . Following the organ supply: assessing the benefit of inter-DSA travel in liver transplantation. Transplantation. 2013;95(2):361-371. doi:10.1097/TP.0b013e3182737cfb - DOI - PubMed
    1. Haugen CE, Ishaque T, Sapirstein A, Cauneac A, Segev DL, Gentry S. Geographic disparities in liver supply/demand ratio within fixed-distance and fixed-population circles. Am J Transplant. 2019;19(7):2044-2052. doi:10.1111/ajt.15297 - DOI - PMC - PubMed

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