Factors that affect deceased donor liver transplantation rates in the United States in addition to the Model for End-stage Liver Disease score.

Under an ideal implementation of Model for End-Stage Liver Disease (MELD)-based liver allocation, the only factors that would predict deceased donor liver transplantation (DDLT) rates would be the MELD score, blood type, and donation service area (DSA). We aimed to determine whether additional factors are associated with DDLT rates in actual practice. Data from the Scientific Registry of Transplant Recipients for all adult candidates wait-listed between March 1, 2002 and December 31, 2008 (n = 57,503) were analyzed. Status 1 candidates were excluded. Cox regression was used to model covariate-adjusted DDLT rates, which were stratified by the DSA, blood type, liver-intestine policy, and allocation MELD score. Inactive time on the wait list was not modeled, so the computed DDLT hazard ratios (HRs) were interpreted as active wait-list candidates. Many factors, including the candidate's age, sex, diagnosis, hospitalization status, and height, prior DDLT, and combined listing for liver-kidney or liver-intestine transplantation, were significantly associated with DDLT rates. Factors associated with significantly lower covariate-adjusted DDLT rates were a higher serum creatinine level (HR = 0.92, P < 0.001), a higher bilirubin level (HR = 0.99, P = 0.001), and the receipt of dialysis (HR = 0.83, P < 0.001). Mild ascites (HR = 1.15, P < 0.001) and hepatic encephalopathy (grade 1 or 2, HR = 1.05, P = 0.02; grade 3 or 4, HR = 1.10, P = 0.01) were associated with significantly higher adjusted DDLT rates. In conclusion, adjusted DDLT rates for actively listed candidates are affected by many factors aside from those integral to the allocation system; these factors include the components of the MELD score itself as well as candidate factors that were considered but were deliberately omitted from the MELD score in order to keep it objective. These results raise the question whether additional candidate characteristics should be explicitly incorporated into the prioritization of wait-list candidates because such factors are already systematically affecting DDLT rates under the current allocation system.

Sharma P ，Schaubel DE ，Messersmith EE ，Guidinger MK ，Merion RM ... -  《-》

Racial and ethnic disparities in access to liver transplantation.

Access to liver transplantation is reportedly inequitable for racial/ethnic minorities, but inadequate adjustments for geography and disease progression preclude any meaningful conclusions. We aimed to evaluate the association between candidate race/ethnicity and liver transplant rates after thorough adjustments for these factors and to determine how uniform racial/ethnic disparities were across Model for End-Stage Liver Disease (MELD) scores. Chronic end-stage liver disease candidates initially wait-listed between February 28, 2002 and February 27, 2007 were identified from Scientific Registry for Transplant Recipients data. The primary outcome was deceased donor liver transplantation (DDLT); the primary exposure covariate was race/ethnicity (white, African American, Hispanic, Asian, and other). Cox regression was used to estimate the covariate-adjusted DDLT rates by race/ethnicity, which were stratified by the donation service area and MELD score. With averaging across all MELD scores, African Americans, Asians, and others had similar adjusted DDLT rates in comparison with whites. However, Hispanics had an 8% lower DDLT rate versus whites [hazard ratio (HR) = 0.92, P = 0.011]. The disparity among Hispanics was concentrated among patients with MELD scores < 20, with HR = 0.84 (P = 0.021) for MELD scores of 6 to 14 and HR = 0.85 (P = 0.009) for MELD scores of 15 to 19. Asians with MELD scores < 15 had a 24% higher DDLT rate with respect to whites (HR = 1.24, P = 0.024). However, Asians with MELD scores of 30 to 40 had a 46% lower DDLT rate (HR = 0.54, P = 0.004). In conclusion, although African Americans did not have significantly different DDLT rates in comparison with similar white candidates, race/ethnicity-based disparities were prominent among subgroups of Hispanic and Asian candidates. By precluding the survival benefit of liver transplantation, this inequity may lead to excess mortality for minority candidates.

Mathur AK ，Schaubel DE ，Gong Q ，Guidinger MK ，Merion RM ... -  《-》

Quantifying Sex-Based Disparities in Liver Allocation.

Locke JE ，Shelton BA ，Olthoff KM ，Pomfret EA ，Forde KA ，Sawinski D ，Gray M ，Ascher NL ... -  《-》

Outcomes for liver transplant candidates listed with low model for end-stage liver disease score.

Kwong AJ ，Lai JC ，Dodge JL ，Roberts JP ... -  《-》

Impact of Model for End-stage Liver Disease Score-based Allocation System in Korea: A Nationwide Study.

Lee J ，Kim DG ，Lee JY ，Lee JG ，Joo DJ ，Kim SI ，Kim MS ... -  《-》