Disparities in liver transplantation before and after introduction of the MELD score.
BACKGROUND
In February 2002, the allocation system for liver transplantation became based on the Model for End-Stage Liver Disease (MELD) score. Before MELD, black patients were more likely to die or become too sick to undergo liver transplantation compared with white patients. Little information exists regarding sex and access to liver transplantation.


OBJECTIVE
To determine the association between race, sex, and liver transplantation following introduction of the MELD system.


METHODS
A retrospective cohort of black and white patients (> or = 18 years) registered on the United Network for Organ Sharing liver transplantation waiting list between January 1, 1996, and December 31, 2000 (pre-MELD cohort, n = 21 895) and between February 28, 2002, and March 31, 2006 (post-MELD cohort, n = 23 793).


METHODS
Association between race, sex, and receipt of a liver transplant. Separate multivariable analyses evaluated cohorts within each period to identify predictors of time to death and the odds of dying or receiving liver transplantation within 3 years of listing. Patients with hepatocellular carcinoma were analyzed separately.


RESULTS
Black patients were younger (mean [SD], 49.2 [10.7] vs 52.4 [9.2] years; P < .001) and sicker (MELD score at listing: median [interquartile range], 16 [12-22] vs 14 [11-19]; P < .001) than white patients on the waiting list for both periods. In the pre-MELD cohort, black patients were more likely to die or become too sick for liver transplantation than white patients (27.0% vs 21.7%) within 3 years of registering on the waiting list (odds ratio [OR], 1.51; 95% confidence interval (CI), 1.15-1.98; P = .003). In the post-MELD cohort, black race was no longer associated with increased likelihood of death or becoming too sick for liver transplantation (26.5% vs 22.0%, respectively; OR, 0.96; 95% CI, 0.74-1.26; P = .76). Black patients were also less likely to receive a liver transplant than white patients within 3 years of registering on the waiting list pre-MELD (61.6% vs 66.9%; OR, 0.75; 95% CI, 0.59-0.97; P = .03), whereas post-MELD, race was no longer significantly associated with receipt of a liver transplant (47.5% vs 45.5%, respectively; OR, 1.04; 95% CI, 0.84-1.28; P = .75). Women were more likely than men to die or become too sick for liver transplantation post-MELD (23.7% vs 21.4%; OR, 1.30; 95% CI, 1.08-1.47; P = .003) vs pre-MELD (22.4% vs 21.9%; OR, 1.08; 95% CI, 0.91-1.26; P = .37). Similarly, women were less likely than men to receive a liver transplant within 3 years both pre-MELD (64.8% vs 67.6%; OR, 0.80; 95% CI, 0.70-0.92; P = .002) and post-MELD (39.9% vs 48.7%; OR, 0.70; 95% CI, 0.62-0.79; P < .001).


CONCLUSIONS
Following introduction of the MELD score to the liver transplantation allocation system, race was no longer associated with receipt of a liver transplant or death on the waiting list, but disparities based on sex remain.
Moylan
Cynthia A
CA
Division of Gastroenterology, Duke University Medical Center, PO Box 3913, Durham, NC 27710, USA. moyla003@mc.duke.edu
Brady
Carla W
CW
Johnson
Jeffrey L
JL
Smith
Alastair D
AD
Tuttle-Newhall
Janet E
JE
Muir
Andrew J
AJ
D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D005260:Female; D015276:Health Care Rationing; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D017093:Liver Failure / Q000601:surgery; D016031:Liver Transplantation / Q000208:ethnology / Q000401:mortality / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012720:Severity of Illness Index; D012737:Sex Factors; D012959:Socioeconomic Factors; D009927:Tissue and Organ Procurement; D014481:United States; D014850:Waiting Lists; D044465:White People / Q000706:statistics & numerical data