Disparities in Liver Transplantation Before and After Introduction of the MELD Score

Abstract

Context In February 2002, the allocation system for liver transplantation became based on the Model for End-Stage Liver Disease (MELD) score. Before MELD, black patients were more likely to die or become too sick to undergo liver transplantation compared with white patients. Little information exists regarding sex and access to liver transplantation. Objective To determine the association between race, sex, and liver transplantation following introduction of the MELD system. Design, Setting, and Patients A retrospective cohort of black and white patients (≥ 18 years) registered on the United Network for Organ Sharing liver transplantation waiting list between January 1, 1996, and December 31, 2000 (pre-MELD cohort, n=21 895) and between February 28, 2002, and March 31, 2006 (post-MELD cohort, n=23 793). Main Outcome Measures Association between race, sex, and receipt of a liver transplant. Separate multivariable analyses evaluated cohorts within each period to identify predictors of time to death and the odds of dying or receiving liver transplantation within 3 years of listing. Patients with hepatocellular carcinoma were analyzed separately. Results Black patients were younger (mean [SD], 49.2 [10.7] vs 52.4 [9.2] years; P < .001) and sicker (MELD score at listing: median [interquartile range], 16 [12–22] vs 14 [11–19]; P < .001) than white patients on the waiting list for both periods. In the pre-MELD cohort, black patients were more likely to die or become too sick for liver transplantation than white patients (27.0% vs 21.7%) within 3 years of registering on the waiting list (odds ratio [OR], 1.51; 95% confidence interval (CI), 1.15–1.98; P = .003). In the post-MELD cohort, black race was no longer associated with increased likelihood of death or becoming too sick for liver transplantation (26.5% vs 22.0%, respectively; OR, 0.96; 95% CI, 0.74–1.26; P = .76). Black patients were also less likely to receive a liver transplant than white patients within 3 years of registering on the waiting list pre-MELD (61.6% vs 66.9%; OR, 0.75; 95% CI, 0.59–0.97; P = .03), whereas post-MELD, race was no longer significantly associated with receipt of a liver transplant (47.5% vs 45.5%, respectively; OR, 1.04;95%CI, 0.84–1.28; P = .75).Women were more likely than men to die or become too sick for liver transplantation post-MELD (23.7% vs 21.4%; OR, 1.30; 95%CI, 1.08–1.47; P = .003) vs pre-MELD (22.4% vs 21.9%; OR, 1.08; 95% CI, 0.91–1.26; P = .37). Similarly, women were less likely than men to receive a liver transplant within 3 years both pre-MELD (64.8% vs 67.6%; OR, 0.80; 95% CI, 0.70–0.92; P = .002) and post-MELD (39.9% vs 48.7%; OR, 0.70; 95% CI, 0.62–0.79; P < .001). Conclusion Following introduction of the MELD score to the liver transplantation allocation system, race was no longer associated with receipt of a liver transplant or death on the waiting list, but disparities based on sex remain.

Persistent disparities in liver transplantation for patients with hepatocellular carcinoma in the United States, 1998 through 2007

“…[7][8][9] Our finding that AA patients with HCC had poorer survival than their white counterparts is in agreement with the findings of Artinyan et al, 10 who also reported that survival differences persisted among patients who underwent LT. In contrast to Moylan et al, 12 who reported that racial disparity in the use of LT was decreasing over time, we found no significant change in racial/ethnic disparities with regard to the use of LT for HCC between 1998 and 2007. However, Moylan et al studied patients with all etiologies of endstage liver disease who were on the LT waiting list.…”

“…However, Moylan et al studied patients with all etiologies of endstage liver disease who were on the LT waiting list. 12 The current study has several potential limitations. Because we did not have the information required to calculate each patient's MELD score, we used closely related comorbidity data regarding liver disease, renal failure, coagulopathy, and other conditions, which were strong predictors of undergoing LT, although they were not as accurate as the MELD scores.…”

“…After the introduction of the MELD score, AA race was no longer associated with the receipt of LT or an increased likelihood of death while on the waiting list. 12 Because this study included patients with all forms of end-stage liver disease and only patients who were registered on the LT waiting list, we conducted a study focused on patients with HCC, irrespective of registration on the LT waiting list, using data from the National Cancer Data Base (NCDB). We examined whether disparities in the use of LT for HCC changed over a 10-year time period, and whether any disparities noted might be explained by differences in neighborhood socioeconomic status (SES), insurance status, geographic region, tumor size, or comorbid medical conditions.…”

Race, ethnicity, and socioeconomic status influence the survival of patients with hepatocellular carcinoma in the United States

“…Although black patients generally are under represented on transplantation waiting lists, 23,24 the subset of patients in the UNOS database who undergo transplantation represents a particularly homogenous population given the ranking methods used for patient listing, particularly in the post-MELD era. This point was reported by Moylan et al, 25 who noted that there was no correlation between race and the receipt of liver transplantation in the era of MELD scores. Our study demonstrates that, after OLT for HCC, significant racial and ethnic disparities in both graft survival and overall survival persist, with black patients again demonstrating a significant survival deficit compared with all other groups.…”

Model for End-stage Liver Disease

“…33,34 Incorporation of serum creatinine into the model resulted in gender disparities in receipt of transplant and higher waitlist mortality among women by 13% compared to men. 35 This is due to the fact that for the given renal function, women tend to have lower serum creatinine compared to men due to lower muscle mass in women.…”