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Exception disparity, size differences make women less likely to receive LT

Compared with men, women on the waitlist for liver transplantation were less likely to receive exception points or achieve first position and were more likely to be declined an organ offer due to donor–recipient size mismatch, according to results of a retrospective study.

“LT is the sole lifesaving treatment for patients with [end-stage liver disease (ESLD)]. Despite efforts to ensure an equitable and objective allocation system, women continue to be less likely than men to receive LT, a disparity that has winded in the [Model for End-Stage Liver Disease (MELD)] era,” Lauren D. Nephew, MD, MSCE, and David Goldberg, MD, from the Hospital of the University of Pennsylvania, and colleagues wrote. “In this study, we show that women are less likely than men to make it to the highest positions on a match run, particularly those women without exception points. Those women who do make it to the highest positions are more likely than men to have organs declined.”

David Goldberg

Researchers accessed the Organ Procurement and Transplantation Network, along with the Standard Transplant Analysis and Research files, to gather data on all patients wait-listed for LT in the U.S. between May 10, 2007, and June 17, 2013. There were 64,995 patients, 10,714 of whom achieved first position on match run. Of all the patients, 23.1% of men and 15.6% of women received exception points (P < .001).

Women without exception points were significantly less likely than men to achieve first position on a match run (OR 0.93; 95% CI, 0.88-0.99) and significantly more likely than men to be declined an organ offer while in the first position (OR 1.16; 95% CI, 1.06-1.26), second position (OR 1.3; 95% CI, 1.2-1.41) or third position (OR 1.31; 95% CI, 1.19-1.44).

Women of smaller stature were more frequently denied organ offers than men of smaller stature (OR 1.18; 95% CI, 1.02-1.37), though men of smaller stature were significantly more likely to be declined an organ offer compared with men of average stature (OR 1.17; 95% CI, 1.01-1.36).

Discordance of weight (OR 2.1; 95% CI, 1.8-2.44), estimated liver weight (OR 4.25; 95% CI, 3.51-5.16) and estimated liver volume (OR 4.81; 95% CI, 3.53-5.19) between recipient and donor were associated with female sex in candidates declined in first position. Additionally, women were significantly more likely to have body surface area discordance with their potential donor compared with men (OR 4.81; 95% CI, 4.09-5.64).

Women with a single liver decline were significantly more likely than men to die or become too sick for LT (OR 1.16; 95% CI, 1.12-1.21); however, when exception point status (OR 1.05; 95% CI, 1.005-1.09) and body surface area were added to the analysis model, the disparity was no longer significant.

“With the incidence of HCC increasing, the numbers of exception points granted to men on the waitlist is likely to grow,” the researchers wrote. “Therefore interventions that focus on the disparity in organ declines, including early consideration of living donor liver transplant, increased access to split-liver donors and/or priority for livers from smaller donors should be considered. Moreover, it will be important to assess whether the disparities due to exception points continue with the new policy on receipt of exception points for patients with HCC.” – by Talitha Bennett

Disclosure: The researchers report no relevant financial disclosures.