Shorter Height Is Associated With Lower Probability of Liver Transplantation in Patients With Hepatocellular Carcinoma

Abstract

Background. The effect of height and sex on liver transplantation (LT) for hepatocellular carcinoma (HCC) remains unclear. Methods. Using United Network for Organ Sharing (UNOS) data, 14 844 HCC patients listed for LT from 2005 to 2015 were identified. Cumulative incidence of waitlist events (LT and dropout for death or too sick) were calculated and modeled using Fine and Gray competing risk regression. Results. Short (SWR), mid (MWR), and long (LWR) UNOS wait regions comprised 25%, 42%, and 33% of the cohort. Three-year cumulative incidence of LT was lower in shorter height patients (≤150, 151–165, and >185 cm; 70.8%, 76.7%, and 83.5%; P < 0.001) and women (78.2% versus 79.8%; P < 0.001). On multivariable analysis, shorter height (≤150, 151–165 cm, hazard ratio [HR] versus >185 cm) was associated with lower probability of LT (0.81 and 0.89; P = 0.02) and greater dropout (HR 1.99 and 1.43; P < 0.001). Female sex was not associated with LT overall, but a significant sex and wait region interaction (P = 0.006) identified lower LT probability for women in MWR (HR versus men, 0.91; P = 0.02). Conclusions. Despite uniform HCC Model for End-Stage Liver Disease exception across height and sex, shorter patients and females in MWR have lower probability of LT. Consideration should be given to awarding additional Model for End-Stage Liver Disease exception points to these patients.

Awarding additional MELD points to the shortest waitlist candidates improves sex disparity in access to liver transplant in the United States

“…8,9 Under current UNOS policy women experience lower rates of LT and higher rates of waitlist dropout than male LT candidates. [8][9][10][11][12][13][14] As described in the introduction, height differences contribute significantly to sex-based disparities in LT outcomes.…”

“…Notably, the introduction of the MELD score has created disparities between men and women that did not exist previously. 8,9 For example, women are now up to 30% less likely than men to undergo LT. 8,10,11,12 Women also have worse waitlist outcomes than men. 8,12,13,14 Compared to men with the same MELD score, women are at a 19% higher risk of death on the LT waitlist and are 10% more likely than men to be removed from the LT waitlist due to being too sick to transplant.…”

“…First, differences in serum creatinine. 11,13,16,17 Serum creatinine, a key component of the MELD score, is on average lower in women due to lower muscle mass. 18 Thus, MELD score may underestimate disease severity in women.…”

“…13,19 Sex differences in size-appropriate organs may play a significant role in women's increased waitlist mortality. 11,13,20,21 Most deceased donor livers come from men, leading to technical challenges using these organs in smaller individuals, such as women. 22,23,24 The pool of adult donor livers has relatively few small livers nationally and pediatric livers are prioritized to pediatric patients.…”

India: Gender Disparities in Organ Donation and Transplantation

“…Female donors are frequently disadvantaged because of size mismatches. 6 Gender disparity in access to liver transplantation is due to limitations in model for end-stage liver disease calculation in addition to donor-recipient size mismatches. 7 Interestingly, deceased liver donors are more frequently male linked potentially to more frequent comorbid conditions and, paradoxically, improved access to medical care.…”