Smaller liver transplant candidates wait up to 55 days longer than other recipients
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Key takeaways:
- Liver transplant candidates with the lowest body surface area waited 55 days longer than those with the highest BSAs.
- Allocation policies should prioritize matching small donors with small recipients.
Liver transplant candidates with a small stature experienced longer waitlist times and had lower rates of transplant, with the smallest 25% of candidates most affected, according to study results in JAMA Surgery.
“As a liver transplant surgeon, I had noticed that small candidates on the waitlist seem to wait longer to get a liver transplant, even if they are at the top of the list,” Catherine E. Kling, MD, MPH, assistant professor in the division of transplant surgery and program director for the Abdominal Transplant Surgery Fellowship at the University of Washington, told Healio. “It is very easy to find an appropriately sized liver for large candidates on the waitlist, but finding a small liver for small candidates can be very difficult.”
She continued, “This was something we wanted to study and quantify — to describe the magnitude of the disparity and see if we could propose any potential policy solutions to overcome the disparity.”
In a retrospective analysis, Kling and colleagues examined data from 41,341 donors (60.1% men; median age, 42 years) and 84,201 waitlist candidates (63.8% men; median age, 57 years). Researchers matched donors to waitlist candidates based on predefined body surface area (BSA) ratio limits and categorized recipients into six groups according to BSA percentile.
Studied outcomes included time on the waitlist, assigned MELD score and proportion of patients who underwent transplant.
According to results, women represented the majority of the two smallest BSA groups at 84% and 61.1%, respectively. For each increase in BSA group number, waitlist time decreased (234 days in group 1 vs. 179 days in group 6) and the proportion of transplantations increased (46% vs. 57%). MELD score also was lowest in group 1 and increased by with increasing BSA.
“Small candidates, measured by body surface area in this study, do in fact wait longer on the waitlist to get a liver transplant,” Kling said. “Women make up the majority of small candidates, but this is not just an issue for women; small men are likewise affected.”
Based on allocation rules, recipients in the lowest BSA groups (groups 1 and 2) and the highest BSA group (group 6) were disadvantaged with 37%, 7.4% and 6.8%, respectively, fewer livers allocated. “We noted that the smallest 25% of waitlist candidates were most affected,” Kling said. “A policy solution that directs the smallest 10% of livers to the smallest 15% of candidates overcame this disparity.”
Kling acknowledged that there is uncertainly whether height or body surface area is the best way to identify small candidates and donors with small livers — or if a better measure exists. “Other measures that have been suggested are more direct measures of liver size, such as liver volume or the anteroposterior diameter of the right lobe of the liver,” she noted, “but these measures would requiring imaging of every donor and recipient.”
According to Kling, the liver transplant community is currently rethinking how to allocate livers to candidates on the waitlist. Small stature is being proposed as a factor to be included in the new allocation model, as that has been identified as a risk factor for not getting a transplant.
“Finding a way to appropriately identify the small candidates at risk, the donors with small livers that could benefit them and match the two is important to overcome this described disparity.”
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