Gender disparity in liver transplant waiting-list mortality: The importance of kidney function

Abstract

Previous studies of men and women on the liver transplant (LT) waiting list suggested a higher risk of mortality for women while on the waiting list without taking transplantation rates into account. The objective of this study was to compare men and women with respect of dying within three years of registration on the LT waiting list taking into account both the immediate mortality risks and transplantation rates. The analysis was based on Organ Procurement and Transplantation Network data of patients with End-Stage Liver Disease (ESLD) on the waiting list registered between February 2002 and August 2009. Competing risk survival analysis was performed to assess gender disparity in waiting list mortality. 42,322 patients and 610,762 person-months of waiting list experience were included in the analysis. The risk of dying within three years of listing was 19% and 17% in women and men, respectively (P<0.0001). Among patients with kidney disease, especially those with estimated glomerular filtration rate (eGFR) ≥ 15 and < 30 ml/min/1.73m2, not on dialysis, women had a substantially higher risk of dying on the waiting list within three years of registration than men (26% vs. 20%, P=0.001). This disparity was related to lower transplantation rates in women; (transplantation rate ratio=0.68, P<0.0001). Controlling for eGFR and other variables related to mortality risk, the overall female-male disparity disappeared. In conclusion, among patients with ESLD with kidney dysfunction, not on dialysis, there is a substantial gender disparity in LT waiting list mortality. Our analysis suggests that this is explained by the fact that, in this group, women had lower transplant rates than men. The lower transplant rates can be explained, in part, by the fact that MELD scores tend to be lower for women than for men as they are based on serum creatinine rather than GFR.

481 Prevalence, Severity and Impact of Renal Dysfunction in Acute Liver Failure on the U.S. Liver Transplant Waiting List

“…We reported survival outcomes for two distinct time periods: 1) overall outcomes during entire time on the waiting list; and 2) all-cause mortality on the waiting list during 6 weeks after listing for ALF. A total of 91 patients were excluded from the survival analysis if their outcome on the waiting list was unknown (60), underwent living donor liver transplantation (10), transplanted at another center (multiple listing) (1), transferred to another center (1), refused liver transplant (2) or died during transplant procedure (17). To determine overall outcomes during entire time on the waiting list analysis, patients were followed from the time of listing until death, removal from the list due to improvement or deterioration, transplantation or until their last follow-up on the liver transplant waiting list.…”

“…Renal dysfunction in the setting of ALF has been associated with decreased survival 8 . Accurate assessment of the severity of renal dysfunction is crucial as it correlates with increased morbidity and mortality in patients with acute and chronic liver disease [8][9][10] . The stage and severity of acute kidney injury is an independent predictor of mortality in patients with chronic liver disease 9 .…”

Gender disparity and MELD in liver transplantation

“…A further recent study [7] again showed that women had lower transplantation rates and a substantially higher mortality risk on the LT waiting list, particularly when eGFR was between 15 and 30 ml/min, due to underestimation of renal dysfunction in women, when Cr was used for MELD score calculation.…”

“…As ''true'' GFR is difficult to perform routinely, and new serum markers, such as cystatin C and its mathematical formulae, seem to offer no significant advantage, compared to Cr and the MDRD formula, in patients with cirrhosis [8], a different parameter is needed. Thus, a simple increase of points should be instituted for women awaiting LT when MELD is used, or indeed in other formulae that use Cr, as unequal access to transplantation between men and women has now been shown by several groups [1,4,6,7] following our first report [2].…”

Gender Mainstreaming and Transplant Surgery

“…53% of women have preformed lymphocytotoxic antibodies against 50% of random lymphocyte donors (vs. 32% of men; p < 0.01), while 28% of women and 13% of men have antibodies against random donors (p < 0.01) [1,12]. Third, simple anatomic preconditions can cause a size mismatch of recipient and graft, excluding small females as recipients for large grafts [2,13,14]. Furthermore, the size of the recipient overall may cause a bias in the allocation process.…”