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. 2024 Jan 1;108(1):225-234.
doi: 10.1097/TP.0000000000004701. Epub 2023 Jun 21.

Racial and Ethnic Disparities in Liver Transplantation for Alcohol-associated Liver Diseases in the United States

Thomas G Cotter  1 , Mack C Mitchell  1 , Mausam J Patel  2 , Ahmad Anouti  1 , Sarah R Lieber  1 , Nicole E Rich  1 , Juan Pablo Arab  3 , Luis Antonio Díaz  4 , Jeremy Louissaint  1 , Thomas Kerr  1 , Arjmand R Mufti  1 , Steven I Hanish  5 , Parsia A Vagefi  5 , Madhukar S Patel  5 , Lisa B VanWagner  1 , William M Lee  1 , Jacqueline G O'Leary  1 , Amit G Singal  1
Affiliations

Racial and Ethnic Disparities in Liver Transplantation for Alcohol-associated Liver Diseases in the United States

Thomas G Cotter et al. Transplantation. .

Abstract

Background: Emerging data suggest disparities exist in liver transplantation (LT) for alcohol-associated liver disease (ALD). As the incidence of ALD increases, we aimed to characterize recent trends in ALD LT frequency and outcomes, including racial and ethnic disparities.

Methods: Using United Network for Organ Sharing/Organ Procurement and Transplantation Network data (2015 through 2021), we evaluated LT frequency, waitlist mortality, and graft survival among US adults with ALD (alcohol-associated hepatitis [AH] and alcohol-associated cirrhosis [AAC]) stratified by race and ethnicity. We used adjusted competing-risk regression analysis to evaluate waitlist outcomes, Kaplan-Meier analysis to illustrate graft survival, and Cox proportional hazards modeling to identify factors associated with graft survival.

Results: There were 1211 AH and 26 526 AAC new LT waitlist additions, with 970 AH and 15 522 AAC LTs performed. Compared with non-Hispanic White patients (NHWs) with AAC, higher hazards of waitlist death were observed for Hispanic (subdistribution hazard ratio [SHR] = 1.23, 95% confidence interval [CI]: 1.16-1.32), Asian (SHR = 1.22, 95% CI:1. 01-1.47), and American Indian/Alaskan Native (SHR = 1.42, 95% CI: 1.15-1.76) candidates. Similarly, significantly higher graft failures were observed in non-Hispanic Black (HR = 1.32, 95% CI: 1.09-1.61) and American Indian/Alaskan Native (HR = 1.65, 95% CI: 1.15-2.38) patients with AAC than NHWs. We did not observe differences in waitlist or post-LT outcomes by race or ethnicity in AH, although analyses were limited by small subgroups.

Conclusions: Significant racial and ethnic disparities exist for ALD LT frequency and outcomes in the United States. Compared with NHWs, racial and ethnic minorities with AAC experience increased risk of waitlist mortality and graft failure. Efforts are needed to identify determinants for LT disparities in ALD that can inform intervention strategies.

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Conflict of interest statement

M.C.M., T.G.C., and T.K. receive salary support from the National Institutes of Health (NIH) (U01 AA 026975). T.K. consults for Alexion. A.G.S.’s research is supported by R01 MD012565 and R01 CA256977. N.E.R. is supported by K08 CA259236. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The funding agencies had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation of the manuscript. W.M.L. is supported by U-01DK58369 and by research support from Intercept, Aurora, Gilead, Novo Nordisk, Alexion, Eiger, Camurus, and Lipocine, and consults for Forma, SeaGen, GSK, Karuna, and Cortexyme; none of these relationships pertain to alcohol-associated liver disease. L.B.V. consults for Gerson Lehrman Group and Noble Insights, receives grant support from W.L. Gore & Associates, and serves as an expert witness. The other authors declare no conflicts of interest.

Figures

Figure 1.
Figure 1.. AAH and AAC Waitlist Additions and Liver Transplant Frequencies 2015–2021
Total numbers of waitlist additions or transplants each year are provided above each bar graph. For AAC liver transplants, the annual percentage (%) of AAC LTs over total adult LTs is provided. AAC, alcohol-associated cirrhosis; AH, alcohol-associated hepatitis; NHW, non-Hispanic White; NHB, non-Hispanic Black.
Figure 2:
Figure 2:. Waitlist Mortality among ALD Liver Transplant Candidates
This figure demonstrates higher hazards of waitlist death for non-Hispanic Blacks (B) and Hispanics (D) compared to non-Hispanic Whites in alcohol-associated cirrhosis. There were no differences observed in waitlist mortality in alcohol-associated hepatitis patients (A, C). Of note, these analyses were adjusted for patient age, sex, waitlisting physiological MELD score, initial BMI, presence of diabetes, highest educational status, and employment status. AAC, alcohol-associated cirrhosis; AH, alcohol-associated hepatitis; NHW, non-Hispanic White; NHB, non-Hispanic Black.
Figure 3:
Figure 3:
This figure shows that non-Hispanic Blacks and AIANs have a higher risk of post-liver transplant graft failure for AAC (B). There were no differences in AH LT outcomes. AAC, alcohol-associated cirrhosis; AH, alcohol-associated hepatitis; AIAN, American Indian/Alaskan Native; NHW, non-Hispanic White; NHB, non-Hispanic Black.
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References

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