Liver transplant rates for HCC decline across all races after 2015 MELD policy change
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Key takeaways:
- Asian patients had the highest 5-year survival before and after the 2015 policy change.
- Black/African American race was associated with increased mortality compared with white race before and after the change.
Asian patients with hepatocellular carcinoma had the lowest waitlist dropout rates and highest 5-year survival after liver transplantation before and after the policy change, while Black or African American patients had the worst outcomes.
“Despite efforts to reduce disparities in LT, such as the Share 35 policy, split liver transplant or the increasing utilization of living donor LTs, there is still a significant gap in access and outcomes among different racial groups,” Behnam Saberi, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School, and colleagues wrote in JAMA Network Open. “It is well known that Latinx/o/a and Black or African American patients are less frequently referred to LT centers and have a lower chance of getting on the waiting list for LT.”
They continued: “Still, there are limited recent data on characteristics, outcomes and predictors of survival in patients with HCC undergoing LT according to race, particularly following the 2015 MELD exception policy change.”
In a retrospective cohort study, Saberi and colleagues used data from the United Network Organ Sharing/Organ Procurement Transplant Network to quantify racial disparities in transplant for HCC and mortality after LT, comparing survival rates before (era 1 = 2010-2015) vs. after (era 2 = 2016-2021) the MELD policy change.
They included 12,031 adults (mean age, 60.8 years; 75.3% men) with HCC waitlisted for LT between 2003 and 2021, most of whom were white (60.1%), followed by Latinx/o/a (21.5%) and Black or African American (9.7%).
Study results showed the proportion of LT for HCC decreased across all races following the policy change, while dropout rates remained steady compared with patients who did not have HCC.
Asian patients had the lowest dropout rate at 1 year in eras 1 (16%) and 2 (17%), while Black or African American patients had the highest rate in era 1 (24%). In era 2, Black/African American, white and Latinx/o/a patients had the same dropout rate (23%).
Further, Asian patients had the highest 5-year survival following LT in both eras (82% and 86%, respectively), while Black/African American patients had the worst (71% and 79%).
Researchers also reported that older recipient and donor age, male sex, encephalopathy, diabetes, higher MELD, higher creatinine and lower albumin were associated with mortality in both eras, as was Black or African American race compared with white race (HR = 1.17; 95% CI, 1.05-1.35 and HR = 1.31; 95% CI, 1.1-1.56).
Moreover, era 2 was associated with improved survival compared with era 1 for LT recipients with HCC (HR = 0.72; 95% CI, 0.67-0.77).
“Our findings reveal a notable decrease in the proportion of LT on the waiting list for HCC among all races following the policy change,” Saberi and colleagues concluded. “These findings contribute to the existing knowledge and understanding of factors influencing liver transplant outcomes, albeit within the constraints of the available data and study design.”
They continued, “Ultimately, achieving health equity in the field of LT necessitates a comprehensive approach that considers the intricate interplay of social, cultural and systemic factors.”
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