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Kanneganti M, Byhoff E, Serper M, Olthoff KM, Bittermann T. Neighborhood-level social determinants of health measures independently predict receipt of living donor liver transplantation in the United States. Liver Transpl 2024; 30:618-627. [PMID: 38100175 DOI: 10.1097/lvt.0000000000000313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 12/06/2023] [Indexed: 01/10/2024]
Abstract
Disparities exist in the access to living donor liver transplantation (LDLT) in the United States. However, the association of neighborhood-level social determinants of health (SDoH) on the receipt of LDLT is not well-established. This was a retrospective cohort study of adult liver transplant recipients between January 1, 2005 and December 31, 2021 at centers performing LDLT using the United Network for Organ Sharing database, which was linked through patients' ZIP code to a set of 24 neighborhood-level SDoH measures from different data sources. Temporal trends and center differences in neighborhood Social Deprivation Index (SDI), a validated scale of socioeconomic deprivation ranging from 0 to 100 (0=least disadvantaged), were assessed by transplant type. Multivariable logistic regression evaluated the association of increasing SDI on receipt of LDLT [vs. deceased donor liver transplantation (DDLT)]. There were 51,721 DDLT and 4026 LDLT recipients at 59 LDLT-performing centers during the study period. Of the 24 neighborhood-level SDoH measures studied, the SDI was most different between the 2 transplant types, with LDLT recipients having lower SDI (ie, less socioeconomic disadvantage) than DDLT recipients (median SDI 37 vs. 47; p < 0.001). The median difference in SDI between the LDLT and DDLT groups significantly decreased from 13 in 2005 to 3 in 2021 ( p = 0.003). In the final model, the SDI quintile was independently associated with transplant type ( p < 0.001) with a threshold SDI of ~40, above which increasing SDI was significantly associated with reduced odds of LDLT (vs. reference SDI 1-20). As a neighborhood-level SDoH measure, SDI is useful for evaluating disparities in the context of LDLT. Center outreach efforts that aim to reduce disparities in LDLT could preferentially target US ZIP codes with SDI > 40.
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Affiliation(s)
- Mounika Kanneganti
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Elena Byhoff
- Department of Medicine, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Marina Serper
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kim M Olthoff
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Therese Bittermann
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Yazdanfar M, Zepeda J, Dean R, Wu J, Levy C, Goldberg D, Lammert C, Prenner S, Reddy KR, Pratt D, Forman L, Assis DN, Lytvyak E, Montano-Loza AJ, Gordon SC, Carey EJ, Ahn J, Schlansky B, Korzenik J, Karagozian R, Hameed B, Chandna S, Yu L, Bowlus CL. African American race does not confer an increased risk of clinical events in patients with primary sclerosing cholangitis. Hepatol Commun 2024; 8:e0366. [PMID: 38285883 PMCID: PMC10830082 DOI: 10.1097/hc9.0000000000000366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/01/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND The natural history of primary sclerosing cholangitis (PSC) among African Americans (AA) is not well understood. METHODS Transplant-free survival and hepatic decompensation-free survival were assessed using a retrospective research registry from 16 centers throughout North America. Patients with PSC alive without liver transplantation after 2008 were included. Diagnostic delay was defined from the first abnormal liver test to the first abnormal cholangiogram/liver biopsy. Socioeconomic status was imputed by the Zip code. RESULTS Among 850 patients, 661 (77.8%) were non-Hispanic Whites (NHWs), and 85 (10.0%) were AA. There were no significant differences by race in age at diagnosis, sex, or PSC type. Inflammatory bowel disease was more common in NHWs (75.8% vs. 51.8% p=0.0001). The baseline (median, IQR) Amsterdam-Oxford Model score was lower in NHWs (14.3, 13.4-15.2 vs. 15.1, 14.1-15.7, p=0.002), but Mayo risk score (0.03, -0.8 to 1.1 vs. 0.02, -0.7 to 1.0, p=0.83), Model for End-stage Liver Disease (5.9, 2.8-10.7 vs. 6.4, 2.6-10.4, p=0.95), and cirrhosis (27.4% vs. 27.1%, p=0.95) did not differ. Race was not associated with hepatic decompensation, and after adjusting for clinical variables, neither race nor socioeconomic status was associated with transplant-free survival. Variables independently associated with death/liver transplant (HR, 95% CI) included age at diagnosis (1.04, 1.02-1.06, p<0.0001), total bilirubin (1.06, 1.04-1.08, p<0.0001), and albumin (0.44, 0.33-0.61, p<0.0001). AA race did not affect the performance of prognostic models. CONCLUSIONS AA patients with PSC have a lower rate of inflammatory bowel disease but similar progression to hepatic decompensation and liver transplant/death compared to NHWs.
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Affiliation(s)
- Maryam Yazdanfar
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| | - Joseph Zepeda
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| | - Richard Dean
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| | - Jialin Wu
- Division of Gastroenterology and Hepatology, Schiff Center for Liver Disease, University of Miami, Miami, Florida, USA
| | - Cynthia Levy
- Division of Gastroenterology and Hepatology, Schiff Center for Liver Disease, University of Miami, Miami, Florida, USA
| | - David Goldberg
- Division of Gastroenterology and Hepatology, Schiff Center for Liver Disease, University of Miami, Miami, Florida, USA
| | | | - Stacey Prenner
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - K. Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Lisa Forman
- University of Colorado, Denver, Colorado, USA
| | | | - Ellina Lytvyak
- Division of Preventive Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Aldo J. Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Stuart C. Gordon
- Henry Ford Health and Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | - Joseph Ahn
- Oregon Health Sciences University, Portland, Oregon, USA
| | | | | | | | - Bilal Hameed
- UC San Francisco, San Francisco, California, USA
| | | | - Lei Yu
- University of Washington, Seattle, Washington, USA
| | - Christopher L. Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
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Givens RC. Racial disparities across multiple stages of the deceased organ donation process. Am J Transplant 2024:S1600-6135(24)00068-6. [PMID: 38211654 DOI: 10.1016/j.ajt.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/23/2023] [Accepted: 12/28/2023] [Indexed: 01/13/2024]
Abstract
Pervasive structural violence causes higher organ failure rates among Black Americans and excess Black potential deceased organ donors. Underuse of Black donors would exacerbate organ shortages that disproportionately harm Black transplant candidates. This study investigates racial differences in transit between distinct donation steps among 132 968 potential donors across 557 hospitals and 6 Organ Procurement Organizations (OPOs) from 2015 through 2021. Multilevel multistate modeling with patient covariates and OPO random effects shows adjusted likelihoods (95% confidence interval [CI]) of non-Black versus Black patients transitioning from OPO referral to approach: odds ratio (OR) 1.23 (95% CI 1.18, 1.27), approach to authorization: OR 1.64 (95% CI 1.56, 1.72), authorization to procurement: OR 1.08 (95% CI 1.02, 1.14), and procurement to transplant: OR 0.99 (95% CI 0.93, 1.04). Overall organ utilization rates for Black, Latino, White, and other OPO referrals were 5.88%, 8.17%, 6.78%, and 5.24%, respectively. Adjusting for patient covariates and hospital and OPO random effects, multilevel logistic models estimated that compared with Black patients, Latino, White, and other patients had ORs of organ utilization of 1.82 (95% CI 1.61, 2.04), 3.19 (95% CI 2.91, 3.50), and 1.25 (95% CI 1.06, 1.47), respectively. Nationwide in 2022, donor conversion disparities likely lost more than 1800 donors-70% of whom would have been Black. Achieving racial equity for transplant candidates will require reducing racial disparities in organ donation.
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Affiliation(s)
- Raymond C Givens
- Department of Medicine, Emory University School of Medicine Atlanta, Georgia, USA.
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Dozil SA, Jackson W, Goldberg DS. Geographic disparities in utilization of living donor liver transplants for racial and ethnic minorities in the United States. Liver Transpl 2023; 29:1337-1339. [PMID: 37379029 DOI: 10.1097/lvt.0000000000000193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023]
Affiliation(s)
- Sarah A Dozil
- Department of Medical Education, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Whitney Jackson
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado USA
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine Miami, Florida, USA
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Tien C, Han HH. Current status and challenges of living donor liver transplantation in the United States. Clin Liver Dis (Hoboken) 2023; 22:177-180. [PMID: 38026119 PMCID: PMC10653593 DOI: 10.1097/cld.0000000000000078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/03/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Christine Tien
- Department of Medicine, University of Southern California, Los Angeles, California, USA
| | - Hyosun H. Han
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
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Duffey K, Halegoua-DeMarzio D, Shah AP, Tholey DM. Sex and racial disparities in living donor liver transplantation in the United States. Liver Transpl 2023; 29:1172-1180. [PMID: 37379011 DOI: 10.1097/lvt.0000000000000197] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/21/2023] [Indexed: 06/29/2023]
Abstract
Sex and racial disparities in deceased donor liver transplantation (DDLT) have been described, but this has not been well studied in living donor liver transplantation (LDLT). We aim to examine these disparities in the US LDLT population and identify potential predictors of these differences. From 2002 to 2021, the Organ Procurement and Transplant Network database was queried to characterize the adult LDLT population and evaluate differences between LDLT and DDLT recipients with regard to sex and race. Donor demographics, Model for End-stage Liver Disease (MELD), and socioeconomic data were all included. Of the 4961 LDLT and 99,984 DDLT recipients, males received the majority of LDLT (55% vs. 45%, p < 0.001) and DDLT (67% vs. 33%, p < 0.001) compared to females. There was a significant difference in race between male and female LDLT recipients ( p < 0.001); 84% of male recipients were White and 78% of females. In both groups, females had lower levels of education and were less likely to have private insurance. There were more female living donors (N = 2545, 51%); 50% of female donors donated to males but only 40% of males donated to females. Donor-recipient relationships varied significantly by sex ( p < 0.001); males received more donations from spouses (62% vs. 39%) and siblings (60% vs. 40%). In the LDLT population, significant disparities exist with respect to sex and race that disadvantage women, but these disparities are less pronounced than in the DDLT population. Although further studies are needed, complex clinical and socioeconomic differences as well as donor factors may explain these variations.
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Affiliation(s)
- Katherine Duffey
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Dina Halegoua-DeMarzio
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ashesh P Shah
- Department of Surgery, Division of Transplant, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Danielle M Tholey
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Jones PD, Lai JC, Bajaj JS, Kanwal F. Actionable Solutions to Achieve Health Equity in Chronic Liver Disease. Clin Gastroenterol Hepatol 2023; 21:1992-2000. [PMID: 37061105 PMCID: PMC10330625 DOI: 10.1016/j.cgh.2023.03.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 02/08/2023] [Accepted: 03/26/2023] [Indexed: 04/17/2023]
Abstract
There are well-described racial and ethnic disparities in the burden of chronic liver diseases. Hispanic persons are at highest risk for developing nonalcoholic fatty liver disease, the fastest growing cause of liver disease. Hepatitis B disproportionately affects persons of Asian or African descent. The highest rates of hepatitis C occur in American Indian and Alaskan Native populations. In addition to disparities in disease burden, there are also marked racial and ethnic disparities in access to treatments, including liver transplantation. Disparities also exist by gender and geography, especially in alcohol-related liver disease. To achieve health equity, we must address the root causes that drive these inequities. Understanding the role that social determinants of health play in the disparate health outcomes that are currently observed is critically important. We must forge and/or strengthen collaborations between patients, community members, other key stakeholders, health care providers, health care institutions, professional societies, and legislative bodies. Herein, we provide a high-level review of current disparities in chronic liver disease and describe actionable strategies that have potential to bridge gaps, improve quality, and promote equity in liver care.
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Affiliation(s)
- Patricia D Jones
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Jasmohan S Bajaj
- Virginia Commonwealth University and Central Virginia Veterans Health Care System, Richmond, Virginia
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas
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8
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Abu S, Chen PH, Harris CM. Comparisons between White and Black Patients Hospitalized with Postliver Transplant Complications/Failure. South Med J 2023; 116:524-529. [PMID: 37400095 DOI: 10.14423/smj.0000000000001578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
OBJECTIVES The impact of race on patients presenting to North American hospitals with postliver transplant complications/failure (PLTCF) has not been studied fully. We compared in-hospital mortality and resource utilization outcomes between White and Black patients hospitalized with PLTCF. METHODS This was a retrospective cohort study that evaluated the years 2016 and 2017 from the National Inpatient Sample. Regression analysis was used to determine in-hospital mortality and resource utilization. RESULTS There were 10,805 hospitalizations for adults with liver transplants who presented with PLTCF. White and Black patients with PLTCF made up 7925 (73.3%) hospitalizations from this population. Among this group, 6480 were White (81.7%) and 1445 were Black (18.2%). Blacks were younger than Whites (mean age ± standard error of the mean: 46.8 ± 1.1 vs 53.6 ± 0.39 years, P < 0.01). Blacks were more likely to be female (53.9% vs 37.4%, P < 0.01). Charlson Comorbidity Index scores were not significantly different (scores ≥3: 46.7% vs 44.2%, P = 0.83). Blacks had significantly higher odds for in-hospital mortality (adjusted odds ratio 2.9, confidence interval [CI] 1.4-6.1; P < 0.01). Hospital charges were higher for Blacks compared with Whites (adjusted mean difference $48,432; 95% CI $2708-$94,157, P = 0.03). Blacks had significantly longer lengths of hospital stays (adjusted mean difference 3.1 days, 95% CI 1.1-5.1, P < 0.01). CONCLUSIONS Compared with White patients hospitalized for PLTCF, Black patients had higher in-hospital mortality and resource use. Investigation into causes leading to this health disparity is needed to improve in-hospital outcomes.
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Kardashian A, Serper M, Terrault N, Nephew LD. Health disparities in chronic liver disease. Hepatology 2023; 77:1382-1403. [PMID: 35993341 PMCID: PMC10026975 DOI: 10.1002/hep.32743] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 12/14/2022]
Abstract
The syndemic of hazardous alcohol consumption, opioid use, and obesity has led to important changes in liver disease epidemiology that have exacerbated health disparities. Health disparities occur when plausibly avoidable health differences are experienced by socially disadvantaged populations. Highlighting health disparities, their sources, and consequences in chronic liver disease is fundamental to improving liver health outcomes. There have been large increases in alcohol use disorder in women, racial and ethnic minorities, and those experiencing poverty in the context of poor access to alcohol treatment, leading to increasing rates of alcohol-associated liver diseases. Rising rates of NAFLD and associated fibrosis have been observed in Hispanic persons, women aged > 50, and individuals experiencing food insecurity. Access to viral hepatitis screening and linkage to treatment are suboptimal for racial and ethnic minorities and individuals who are uninsured or underinsured, resulting in greater liver-related mortality and later-stage diagnoses of HCC. Data from more diverse cohorts on autoimmune and cholestatic liver diseases are lacking, supporting the need to study the contemporary epidemiology of these disorders in greater detail. Herein, we review the existing literature on racial and ethnic, gender, and socioeconomic disparities in chronic liver diseases using a social determinants of health framework to better understand how social and structural factors cause health disparities and affect chronic liver disease outcomes. We also propose potential solutions to eliminate disparities, outlining health-policy, health-system, community, and individual solutions to promote equity and improve health outcomes.
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Affiliation(s)
- Ani Kardashian
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Norah Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Simon Comprehensive Cancer Center, Indianapolis, Indiana, USA
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Jesse MT, Jackson WE, Liapakis A, Ganesh S, Humar A, Goldaracena N, Levitsky J, Mulligan D, Pomfret EA, Ladner DP, Roberts JP, Mavis A, Thiessen C, Trotter J, Winder GS, Griesemer AD, Pillai A, Kumar V, Verna EC, LaPointe Rudow D, Han HH. Living donor liver transplant candidate and donor selection and engagement: Meeting report from the living donor liver transplant consensus conference. Clin Transplant 2023:e14954. [PMID: 36892182 DOI: 10.1111/ctr.14954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/14/2023] [Accepted: 02/25/2023] [Indexed: 03/10/2023]
Abstract
INTRODUCTION Living donor liver transplantation (LDLT) is a promising option for mitigating the deceased donor organ shortage and reducing waitlist mortality. Despite excellent outcomes and data supporting expanding candidate indications for LDLT, broader uptake throughout the United States has yet to occur. METHODS In response to this, the American Society of Transplantation hosted a virtual consensus conference (October 18-19, 2021), bringing together relevant experts with the aim of identifying barriers to broader implementation and making recommendations regarding strategies to address these barriers. In this report, we summarize the findings relevant to the selection and engagement of both the LDLT candidate and living donor. Utilizing a modified Delphi approach, barrier and strategy statements were developed, refined, and voted on for overall barrier importance and potential impact and feasibility of the strategy to address said barrier. RESULTS Barriers identified fell into three general categories: 1) awareness, acceptance, and engagement across patients (potential candidates and donors), providers, and institutions, 2) data gaps and lack of standardization in candidate and donor selection, and 3) data gaps regarding post-living liver donation outcomes and resource needs. CONCLUSIONS Strategies to address barriers included efforts toward education and engagement across populations, rigorous and collaborative research, and institutional commitment and resources.
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Affiliation(s)
- Michelle T Jesse
- Transplant Institute, Henry Ford Health System, Detroit, Michigan, USA
| | - Whitney E Jackson
- Division of Gastroenterology and Hepatology, University of Colorado, Aurora, Colorado, USA
| | - AnnMarie Liapakis
- Yale School of Medicine and Yale New Haven Transplant Center, New Haven, Connecticut, USA
| | - Swaytha Ganesh
- Thomas E Starzl Transplant Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Abhinav Humar
- Thomas E Starzl Transplant Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nicolas Goldaracena
- Division of Transplant Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Josh Levitsky
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David Mulligan
- Division of Transplant Surgery, Yale University, New Haven, Connecticut, USA
| | | | - Daniela P Ladner
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John P Roberts
- UCSF Department of Surgery, San Francisco, California, USA
| | - Alisha Mavis
- Pediatric Gastroenterology, Hepatology, and Nutrition, Duke University Health, Durham, North Carolina, USA
| | - Carrie Thiessen
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - James Trotter
- Transplant Hepatology, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Adam D Griesemer
- Department of Surgery, NYU Langone Heath, New York, New York, USA
| | - Anjana Pillai
- Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Vineeta Kumar
- Department of Medicine, Division of Nephrology/Transplant, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University, New York, New York, USA
| | - Dianne LaPointe Rudow
- Recanati/Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
| | - Hyosun H Han
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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11
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Yoeli D, Feldman AG, Choudhury RA, Moore HB, Sundaram SS, Nydam TL, Wachs ME, Pomfret EA, Adams MA, Jackson WE. Can non-directed living liver donation help improve access to grafts and correct socioeconomic disparities in pediatric liver transplantation? Pediatr Transplant 2023; 27:e14428. [PMID: 36329627 PMCID: PMC10132215 DOI: 10.1111/petr.14428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 02/10/2022] [Accepted: 05/05/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Each year, children die awaiting LT as the demand for grafts exceeds the available supply. Candidates with public health insurance are significantly less likely to undergo both deceased donor LT and D-LLD LT. ND-LLD is another option to gain access to a graft. The aim of this study was to evaluate if recipient insurance type is associated with likelihood of D-LLD versus ND-LLD LT. METHODS The SRTR/OPTN database was reviewed for pediatric LDLT performed between January 1, 2014 (Medicaid expansion era) and December 31, 2019 at centers that performed ≥1 ND-LLD LDLT during the study period. A multivariable logistic regression was performed to assess relationship between type of living donor (directed vs. non-directed) and recipient insurance. RESULTS Of 299 pediatric LDLT, 46 (15%) were from ND-LLD performed at 18 transplant centers. Fifty-nine percent of ND-LLD recipients had public insurance in comparison to 40% of D-LLD recipients (p = .02). Public insurance was associated with greater odds of ND-LLD in comparison to D-LLD upon multivariable logistic regression (OR 2.37, 95% CI 1.23-4.58, p = .01). CONCLUSIONS ND-LLD allows additional children to receive LTs and may help address some of the socioeconomic disparity in pediatric LDLT, but currently account for only a minority of LDLT and are only performed at a few institutions. Initiatives to improve access to both D-LLD and ND-LLD transplants are needed.
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Affiliation(s)
- Dor Yoeli
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA.,Division of Abdominal Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Amy G Feldman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatric Medicine, The Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Rashikh A Choudhury
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hunter B Moore
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Shikha S Sundaram
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatric Medicine, The Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Trevor L Nydam
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael E Wachs
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA.,Division of Abdominal Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Elizabeth A Pomfret
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Megan A Adams
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA.,Division of Abdominal Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Whitney E Jackson
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Sempokuya T, Warner J, Azawi M, Nogimura A, Wong LL. Current status of disparity in liver disease. World J Hepatol 2022; 14:1940-1952. [PMID: 36483604 PMCID: PMC9724102 DOI: 10.4254/wjh.v14.i11.1940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/09/2022] [Accepted: 11/16/2022] [Indexed: 11/24/2022] Open
Abstract
Disparities have emerged as an important issue in many aspects of healthcare in developed countries and may be based on race, ethnicity, sex, geographical location, and socioeconomic status. For liver disease specifically, these potential disparities can affect access to care and outcome in viral hepatitis, chronic liver disease, and hepatocellular carcinoma. Shortages in hepatologists and medical providers versed in liver disease may amplify these disparities by compromising early detection of liver disease, surveillance for hepatocellular carcinoma, and prompt referral to subspecialists and transplant centers. In the United States, continued efforts have been made to address some of these disparities with better education of healthcare providers, use of telehealth to enhance access to specialists, reminders in electronic medical records, and modifying organ allocation systems for liver transplantation. This review will detail the current status of disparities in liver disease and describe current efforts to minimize these disparities.
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Affiliation(s)
- Tomoki Sempokuya
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Josh Warner
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Muaataz Azawi
- Division of Gastroenterology and Hepatology, Sanford Center for Digestive Health, Sioux Falls 57105, SD, Uruguay
| | - Akane Nogimura
- Department of Public Health, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Aichi, Japan
- Division of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Aichi, Japan
| | - Linda L Wong
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI 96813, United States
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Althoff AL, Ali MS, O'Sullivan DM, Dar W, Emmanuel B, Morgan G, Einstein M, Richardson E, Sotil E, Swales C, Sheiner PA, Serrano OK. Short- and Long-Term Outcomes for Ethnic Minorities in the United States After Liver Transplantation: Parsing the Hispanic Paradox. Transplant Proc 2022; 54:2263-2269. [DOI: 10.1016/j.transproceed.2022.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 08/03/2022] [Accepted: 08/26/2022] [Indexed: 11/05/2022]
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Are MELD and MELDNa Still Reliable Tools to Predict Mortality on the Liver Transplant Waiting List? Transplantation 2022; 106:2122-2136. [PMID: 35594480 DOI: 10.1097/tp.0000000000004163] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Liver transplantation is the only curative treatment for end-stage liver disease. Unfortunately, the scarcity of donor organs and the increasing pool of potential recipients limit access to this life-saving procedure. Allocation should account for medical and ethical factors, ensuring equal access to transplantation regardless of recipient's gender, race, religion, or income. Based on their short-term prognosis prediction, model for end-stage liver disease (MELD) and MELD sodium (MELDNa) have been widely used to prioritize patients on the waiting list for liver transplantation resulting in a significant decrease in waiting list mortality/removal. Recent concern has been raised regarding the prognostic accuracy of MELD and MELDNa due, in part, to changes in recipients' profile such as body mass index, comorbidities, and general condition, including nutritional status and cause of liver disease, among others. This review aims to provide a comprehensive view of the current state of MELD and MELDNa advantages and limitations and promising alternatives. Finally, it will explore future options to increase the donor pool and improve donor-recipient matching.
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Kaplan A, Wahid N, Lee J, Fortune BE, Halazun KJ, Fox A, Brown RS, Samstein B, Rosenblatt R. Sociodemographic characteristics of living liver donors: Few changes over 20 years. Clin Transplant 2022; 36:e14701. [PMID: 35532183 DOI: 10.1111/ctr.14701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/05/2022] [Accepted: 04/23/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Although there are well-documented challenges in access to living donor liver transplant (LDLT) among recipients, it is unclear whether living liver donors (LLDs) face similar challenges. METHODS We analyzed the UNOS Standard Transplant Analysis and Research database, including LLDs ≥ 18 years in the United States from 1/1998-12/2018. We compared sociodemographic characteristics (age, gender, race/ethnicity, education level, employment status, BMI, and relationship to recipient) of LLDs across three eras-pre-MELD (1998-2002), MELD (2003-2013), and post-direct acting antivirals (DAA) (2014-2018). We also described sociodemographic characteristics of living donor recipients and waitlisted patients. Chi-squared and one-way analysis of variance (ANOVA) were used to compare categorical and continuous variables, respectively. RESULTS From 1998-2018, 4,756 LDLTs and 99,765 DDLTs were performed. Across the three eras, LLD age did not change significantly (p = 0.3), but donors were generally young (mean age 37+/-11). While men comprised most LLDs in the pre-MELD era (55.2%), women surpassed them in the post-DAA era (52.9%), p<0.001. In total, White donors comprised 81.5% of total LLDs, while Black and Asian donors were a small minority of total donors (3.7% and 2.5%, respectively). Most donors had at least a college education and were employed. Educational attainment and employment did not significantly change over the study period. CONCLUSIONS During the last twenty years, LLDs have remained White, employed, highly educated, and young with increasing numbers of women LLDs. The relative lack of change in the characteristics of donors is likely attributable largely to socioeconomic factors, which should be assessed in future investigation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alyson Kaplan
- Department of Gastroenterology and Hepatology, New York Presbyterian Weill Cornell School of Medicine
| | - Nabeel Wahid
- Department of Medicine, New York Presbyterian Weill Cornell School of Medicine
| | - Jihui Lee
- Division of Biostatistics of Department of Population Health Sciences, Weill Cornell School of Medicine
| | - Brett E Fortune
- Department of Gastroenterology and Hepatology, New York Presbyterian Weill Cornell School of Medicine
| | - Karim J Halazun
- Department of Surgery, New York Presbyterian Weill Cornell School of Medicine
| | - Alyson Fox
- Department of Gastroenterology and Hepatology, New York Presbyterian Columbia University Irving Medical Center
| | - Robert S Brown
- Department of Gastroenterology and Hepatology, New York Presbyterian Weill Cornell School of Medicine
| | - Benjamin Samstein
- Department of Surgery, New York Presbyterian Weill Cornell School of Medicine
| | - Russell Rosenblatt
- Department of Gastroenterology and Hepatology, New York Presbyterian Weill Cornell School of Medicine
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A scoping review of inequities in access to organ transplant in the United States. Int J Equity Health 2022; 21:22. [PMID: 35151327 PMCID: PMC8841123 DOI: 10.1186/s12939-021-01616-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/24/2021] [Indexed: 02/06/2023] Open
Abstract
Background Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research. Methods We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes. Results Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant. Conclusions This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01616-x.
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Wadhwani SI, Ge J, Gottlieb L, Lyles C, Beck AF, Bucuvalas J, Neuhaus J, Kotagal U, Lai JC. Racial/ethnic disparities in wait-list outcomes are only partly explained by socioeconomic deprivation among children awaiting liver transplantation. Hepatology 2022; 75:115-124. [PMID: 34387881 PMCID: PMC8934136 DOI: 10.1002/hep.32106] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/20/2021] [Accepted: 07/31/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS Racial/ethnic minority children have worse liver transplant (LT) outcomes. We evaluated whether neighborhood socioeconomic deprivation affected associations between race/ethnicity and wait-list mortality. APPROACH AND RESULTS We included children (age <18) listed 2005-2015 in the Scientific Registry of Transplant Recipients. We categorized patients as non-Hispanic White, Black, Hispanic, and other. We matched patient ZIP codes to a neighborhood socioeconomic deprivation index (range, 0-1; higher values indicate worse deprivation). Primary outcomes were wait-list mortality, defined as death/delisting for too sick, and receipt of living donor liver transplant (LDLT). Competing risk analyses modeled the association between race/ethnicity and wait-list mortality, with deceased donor liver transplant (DDLT) and LDLT as competing risks, and race/ethnicity and LDLT, with wait-list mortality and DDLT as competing risks. Of 7716 children, 17% and 24% identified as Black and Hispanic, respectively. Compared to White children, Black and Hispanic children had increased unadjusted hazard of wait-list mortality (subhazard ratio [sHR], 1.44; 95% CI, 1.18, 1.75 and sHR, 1.48; 95% CI, 1.25, 1.76, respectively). After adjusting for neighborhood deprivation, insurance, and listing laboratory Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease, Black and Hispanic children did not have increased hazard of wait-list mortality (sHR, 1.12; 95% CI, 0.91, 1.39 and sHR, 1.21; 95% CI, 1.00, 1.47, respectively). Similarly, Black and Hispanic children had a decreased likelihood of LDLT (sHR, 0.58; 95% CI, 0.45, 0.75 and sHR, 0.61; 95% CI, 0.49, 0.75, respectively). Adjustment attenuated the effect of Black and Hispanic race/ethnicity on likelihood of LDLT (sHR, 0.79; 95% CI, 0.60, 1.02 and sHR, 0.89; 95% CI, 0.70, 1.11, respectively). CONCLUSIONS Household and neighborhood socioeconomic factors and disease severity at wait-list entry help explain racial/ethnic disparities for children awaiting transplant. A nuanced understanding of how social adversity contributes to wait-list outcomes may inform strategies to improve outcomes.
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Affiliation(s)
| | - Jin Ge
- University of California, San Francisco, San Francisco, CA
| | - Laura Gottlieb
- University of California, San Francisco, San Francisco, CA
| | - Courtney Lyles
- University of California, San Francisco, San Francisco, CA
| | - Andrew F. Beck
- University of Cincinnati College of Medicine, Cincinnati, OH,Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - John Bucuvalas
- Icahn School of Medicine at Mount Sinai, New York, NY,Kravis Children’s Hospital at Mount Sinai, New York, NY
| | - John Neuhaus
- University of California, San Francisco, San Francisco, CA
| | - Uma Kotagal
- University of Cincinnati College of Medicine, Cincinnati, OH,Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Lee BT, Tana MM, Kahn JA, Dara L. We Are Not Immune: Racial and Ethnic Disparities in Autoimmune Liver Diseases. Hepatology 2021; 74:2876-2887. [PMID: 34056734 DOI: 10.1002/hep.31985] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 04/29/2021] [Accepted: 05/25/2021] [Indexed: 12/11/2022]
Abstract
Autoimmune liver diseases are attributed to a complex interplay of biologic, acquired, and environmental factors. Increased prevalence, later stage at presentation, worse response to standard therapy, and transplant-related disparities have all been reported in racial and ethnic minorities such as Black and Latinx patients with autoimmune liver diseases. While biology and inherited genetic predispositions may partly explain these disparities, definitive and universal genetic variations underlying these differences in outcomes have not been defined. Nonetheless, socioeconomic status, access to health care, environmental and societal factors, and implicit provider bias can all contribute to poor patient outcomes. There remains an unmet need to understand and mitigate the factors contributing to health inequity in autoimmune liver diseases. In this review, we summarize the data on racial and ethnic disparities in presentation, treatment response, and outcomes pertaining to autoimmune liver diseases in minority populations, on the premise that understanding disparities is the first step toward reaching health equity.
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Affiliation(s)
- Brian T Lee
- Division of Gastroenterology and Transplant Institute, Loma Linda University Health, Loma Linda, CA
| | - Michele M Tana
- UCSF Liver Center, University of California, San Francisco, CA
- Division of Gastroenterology, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, CA
| | - Jeffrey A Kahn
- USC Research Center for Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Lily Dara
- USC Research Center for Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Abstract
PURPOSE OF REVIEW Living organ donation provides improved access to transplantation, thereby shortening transplant wait times and allowing for more deceased organ transplants. However, disparity in access to living donation has resulted in decreased rates of living donor transplants for some populations of patients. RECENT FINDINGS Though there have been marked improvements in deceased donor equity, there are still challenges as it relates to gender, racial/ethnic, and socio-economic disparity. Improvements in living donation rates in Hispanic and Asian populations are tempered by challenges in African American rates of organ donation. Socio-economic disparity may drive gender disparities in organ donation resulting in disproportionate female living donors. Tailored approaches relating to language-specific interventions as well as directed educational efforts have helped mitigate disparity. Additionally, the use of apolipoprotein1 testing and modifications of glomerular filtration rate calculators may improve rates of African American donation. This review will evaluate recent data in living donor disparity as well as highlight successes in mitigating disparity. SUMMARY Though there are still challenges in living donor disparity, many efforts at tailoring education and access as well as modifying living donor evaluation and identifying systemic policy changes may result in improvements in living donation rates.
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Affiliation(s)
- Reynold I Lopez-Soler
- Section of Renal Transplantation, Edward Hines VA Jr. Hospital, Hines
- Department of Surgery, Division of Intra-Abdominal Transplantation, Stritch School of Medicine, Maywood, Illinois, USA
| | - Raquel Garcia-Roca
- Department of Surgery, Division of Intra-Abdominal Transplantation, Stritch School of Medicine, Maywood, Illinois, USA
| | - David D Lee
- Department of Surgery, Division of Intra-Abdominal Transplantation, Stritch School of Medicine, Maywood, Illinois, USA
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20
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Waitlist Mortality and Posttransplant Outcomes in African Americans with Autoimmune Liver Diseases. J Transplant 2021; 2021:6692049. [PMID: 34394979 PMCID: PMC8357471 DOI: 10.1155/2021/6692049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/11/2021] [Accepted: 07/25/2021] [Indexed: 11/17/2022] Open
Abstract
Background Liver transplantation is indicated in end-stage liver disease due to autoimmune diseases. The liver allocation system can be affected by disparities such as decreased liver transplant referrals for racial minorities, especially African Americans that negatively impact the pre- and posttransplant outcomes. Aim To determine differences in waitlist survival and posttransplant graft survival rates between African American and Caucasian patients with autoimmune liver diseases. Study. The United Network for Organ Sharing database was used to identify all patients with autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis who underwent liver transplant from 1988 to 2019. We compared waitlist survival and posttransplant graft survival between Caucasians and African Americans using Kaplan–Meier curves and Cox regression models. We also evaluated the cumulative incidence of death or delisting for deterioration and posttransplant incidence of death and retransplantation using competing risk analysis. Results African Americans were more likely to be removed from the waitlist for death or clinical deterioration (subdistribution hazard ratio (SHR) 1.26, 95% CI 1–1.58, P=0.046) using competing risk analysis. On multivariate Cox regression analysis, there was no difference in posttransplant graft survival among the two groups (hazard ratio (HR) 1.10, 95% CI 0.98–1.23, P=0.081). Conclusions Despite the current efforts to reduce racial disparities, we found that African Americans are more likely to die on the waitlist for liver transplant and are less likely to be transplanted, with no differences in graft survival rates. The persistence of healthcare disparities continues to negatively impact African Americans.
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21
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Nephew LD, Serper M. Racial, Gender, and Socioeconomic Disparities in Liver Transplantation. Liver Transpl 2021; 27:900-912. [PMID: 33492795 DOI: 10.1002/lt.25996] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/30/2020] [Accepted: 01/13/2021] [Indexed: 12/11/2022]
Abstract
Liver transplantation (LT) is a life-saving therapy; therefore, equitable distribution of this scarce resource is of paramount importance. We searched contemporary literature on racial, gender, and socioeconomic disparities across the LT care cascade in referral, waitlist practices, allocation, and post-LT care. We subsequently identified gaps in the literature and future research priorities. Studies found that racial and ethnic minorities (Black and Hispanic patients) have lower rates of LT referral, more advanced liver disease and hepatocellular carcinoma at diagnosis, and are less likely to undergo living donor LT (LDLT). Gender-based disparities were observed in waitlist mortality and LT allocation. Women have lower LT rates after waitlisting, with size mismatch accounting for much of the disparity. Medicaid insurance has been associated with higher rates of chronic liver disease and poor waitlist outcomes. After LT, some studies found lower overall survival among Black compared with White recipients. Studies have also shown lower literacy and limited educational attainment were associated with increased posttransplant complications and lower use of digital technology. However, there are notable gaps in the literature on disparities in LT. Detailed population-based estimates of the advanced liver disease burden and LT referral and evaluation practices, including for LDLT, are lacking. Similarly, little is known about LT disparities worldwide. Evidence-based strategies to improve access to care and reduce disparities have not been comprehensively identified. Prospective registries and alternative "real-world" databases can provide more detailed information on disease burden and clinical practices. Modeling and simulation studies can identify ways to reduce gender disparities attributed to size or inaccurate estimation of renal function. Mixed-methods studies and clinical trials should be conducted to reduce care disparities across the transplant continuum.
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Affiliation(s)
- Lauren D Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Thuluvath PJ, Amjad W, Zhang T. Liver transplant waitlist removal, transplantation rates and post-transplant survival in Hispanics. PLoS One 2020; 15:e0244744. [PMID: 33382811 PMCID: PMC7774861 DOI: 10.1371/journal.pone.0244744] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/15/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hispanics are the fastest growing population in the USA, and our objective was to determine their waitlist mortality rates, liver transplantation (LT) rates and post-LT outcomes. METHODS All adults listed for LT with the UNOS from 2002 to 2018 were included. Competing risk analysis was performed to assess the association between ethnic group with waitlist removal due to death/deterioration and transplantation. For sensitivity analysis, Hispanics were matched 1:1 to Non-Hispanics using propensity scores, and outcomes of interest were compared in matched cohort. RESULTS During this period, total of 154,818 patients who listed for liver transplant were involved in this study, of them 23,223 (15%) were Hispanics, 109,653 (71%) were Whites, 13,020 (8%) were Blacks, 6,980 (5%) were Asians and 1,942 (1%) were others. After adjusting for differences in clinical characteristics, compared to Whites, Hispanics had higher waitlist removal due to death or deterioration (adjusted cause-specific Hazard Ratio: 1.034, p = 0.01) and lower transplantation rates (adjusted cause-specific Hazard Ratio: 0.90, p<0.001). If Hispanics received liver transplant, they had better patient and graft survival than Non-Hispanics (p<0.001). Compared to Whites, adjusted hazard ratio for Hispanics were 0.88 (95% CI 0.84, 0.92, p<0.001) for patient survival and 0.90 (95% CI 0.86, 0.94, p<0.001) for graft survival. Our analysis in matched cohort showed the consistent results. CONCLUSIONS This study showed that Hispanics had higher probability to be removed from the waitlist due to death, and lower probability to be transplanted, however they had better post-LT outcomes when compared to whites.
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Affiliation(s)
- Paul J. Thuluvath
- Institute for Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Waseem Amjad
- Institute for Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, United States of America
| | - Talan Zhang
- Institute for Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, United States of America
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Spiewak T, Taefi A, Patel S, Li CS, Chak E. Racial disparities of Black Americans hospitalized for decompensated liver cirrhosis. BMC Gastroenterol 2020; 20:245. [PMID: 32727386 PMCID: PMC7391571 DOI: 10.1186/s12876-020-01392-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 07/21/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Racial disparities have been reported in liver transplantation and chronic hepatitis C treatment outcomes. Determining causes of these disparities is important given the racially diverse American population and the economic burden associated with chronic liver disease. METHODS A retrospective study was performed among 463 patients diagnosed with cirrhosis admitted from (January 1, 2013 to January 1, 2018) to a tertiary care academic medical center. Patients were identified based on the International Classification of Diseases (ICD-10) for cirrhosis or its complications. Demographic information, laboratory data, medical comorbidities, insurance and adherence to cirrhosis quality care indicators were recorded to determine their relationship to readmission rates and other healthcare outcomes. RESULTS A total of 463 individual patients with cirrhosis were identified including Whites (n = 241), Hispanics (n = 106), Blacks (n = 50), Asian and Pacific Islander Americans (API, n = 27) and Other (n = 39). A significantly higher proportion of Blacks had Medicaid insurance compared to Whites (40% versus 20%, p = 0.0002) and Blacks had lower median income than Whites ($45,710 versus $54,844, p = 0.01). All groups received high quality cirrhosis care. Regarding healthcare outcomes, Black patients had the highest mean total hospital admissions (6.1 ± 6.3, p = 0.01) and the highest mean number of 30-day re-admissions (2.1 ± 3.7, p = 0.05) compared to all other racial groups. Multivariable proportional odds regression analysis showed that race was a statistically significant predictor of 90-day readmission (p = 0.03). CONCLUSIONS Black Americans hospitalized for complications of cirrhosis may experience significant disparities in healthcare outcomes compared to Whites despite high quality cirrhosis care. Socioeconomic factors may contribute to these disparities.
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Affiliation(s)
- Ted Spiewak
- Department of Internal Medicine, UC Davis Medical Center, Sacramento, California, USA
| | - Amir Taefi
- Department of Gastroenterology and Hepatology, UC Davis Medical Center, 4150 V Street, PSSB 3500, Sacramento, CA, 95817, USA
| | - Shruti Patel
- Department of Internal Medicine, UC Davis Medical Center, Sacramento, California, USA
| | - Chin-Shang Li
- School of Nursing, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Eric Chak
- Department of Gastroenterology and Hepatology, UC Davis Medical Center, 4150 V Street, PSSB 3500, Sacramento, CA, 95817, USA.
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The need for a living donor wellness program. Curr Opin Organ Transplant 2020; 25:311-315. [PMID: 32487890 DOI: 10.1097/mot.0000000000000779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW Living donation has a tremendous impact in bridging the gap between the shortage of organs and the growing list of transplant candidates but remains underutilized as a percentage of total transplants performed. This review focuses on obesity and social determinants of health as potential barriers to the expansion of living kidney donation. RECENT FINDINGS The growing rate of obesity and associated metabolic syndrome make many potential donors unacceptable as donor candidates because of the future risk for developing chronic health conditions, such as hypertension and diabetes. There is also increasing evidence demonstrating socioeconomic differences and racial disparities potentially limit access to living donation in certain populations. These potentially modifiable factors are not exclusive of each other and together serve as significant contributing factors to lower rates of living donation. SUMMARY Living donors make sacrifices to provide the gift of life to transplant recipients, despite the potential risks to their own health. Studies describing risk factors to living donation call attention to the overall need for more action to prioritize and promote the health and well being of living donors.
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Use of Patient Navigators to Reduce Barriers in Living Donation and Living Donor Transplantation. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00280-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kutzler HL, Peters J, O’Sullivan DM, Williamson A, Cheema F, Ebcioglu Z, Einstein M, Rochon C, Ye X, Sheiner P, Singh JU, Sotil EU, Swales C, Serrano OK. Disparities in End-Organ Care for Hispanic Patients with Kidney and Liver Disease: Implications for Access to Transplantation. CURRENT SURGERY REPORTS 2020. [DOI: 10.1007/s40137-020-00248-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ochoa-Allemant P, Ezaz G, Trivedi HD, Sanchez-Fernandez L, Bonder A. Long-term outcomes after liver transplantation in the Hispanic population. Liver Int 2020; 40:437-446. [PMID: 31505081 DOI: 10.1111/liv.14248] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 02/12/2023]
Abstract
BACKGROUND & AIMS Racial/ethnic disparities in liver transplantation (LT) are well-recognized. Although Hispanics represent the largest and youngest minority group in the United States, limited data exist on long-term outcomes. We aimed to investigate long-term post-liver transplant outcomes in Hispanic patients and identify potential disparities compared to a baseline demographic of non-Hispanic white patients. METHODS We performed a retrospective cohort study of first-time liver transplant recipients using the United Network for Organ Sharing database from 2002 to 2013, with follow-up through 2018. The primary outcomes of interest were overall patient and graft survival after LT. RESULTS 45 767 patients underwent LT (85.0% non-Hispanic white, 15.0% Hispanic). Hispanics had lower socioeconomic status, higher prevalence of pretransplant comorbidities and more severe liver disease compared to non-Hispanic whites. Hispanics had similar patient (76.6% vs 75.6%; P = .12) and graft (71.7% vs 70.8%; P = .28) survival at 5 years and significantly better patient (62.9% vs 59.7%; P < .001) and graft (58.6% vs 55.6%; P = .002) survival at 10 years. In multivariable analysis, Hispanics had lower associated all-cause mortality (HR 0.86, 95% CI, 0.82-0.91; P < .001) and graft failure (HR 0.89, 95% CI, 0.85-0.93; P < .001) compared to non-Hispanic whites. In etiology-specific subanalysis, Hispanics transplanted for ALD, NASH and HCV had lower all-cause mortality compared to non-Hispanic whites. CONCLUSIONS Hispanics have similar or better long-term post-LT outcomes compared to non-Hispanic whites despite a worse pretransplant risk factor profile. Further research is needed to clarify if this survival advantage reflects uncaptured protective factors or more stringent transplant selection in the Hispanic population.
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Affiliation(s)
- Pedro Ochoa-Allemant
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ghideon Ezaz
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Hirsh D Trivedi
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Lady Sanchez-Fernandez
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alan Bonder
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Family First: Asian Americans' Attitudes and Behaviors Toward Deceased Organ Donation. J Racial Ethn Health Disparities 2019; 7:72-83. [PMID: 31493296 DOI: 10.1007/s40615-019-00635-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/19/2019] [Accepted: 08/25/2019] [Indexed: 10/26/2022]
Abstract
Asian Americans have substantial transplantation needs but have the lowest rates of organ donation in the USA. As the shortage of transplantable organs persists, the rate of deceased donation by Asian Americans has not kept pace with that of the general population. This report is a qualitative study of organ donation-related attitudes and beliefs of three Asian ethnic groups located in the greater Philadelphia metropolitan area: Chinese, Filipino, and Vietnamese Americans. Guided by a Community Advisory Board representing these groups, we conducted 9 focus groups with a total of 64 participants and subsequent thematic analyses. Six major themes emerged: (1) positive views about organ donation, (2) previous exposure to organ donation, (3) primacy of the family in decision making, (4) mistrust of the healthcare and donation systems, (5) religious and cultural beliefs concerning the body, and (6) isolation from mainstream American society. Although participants expressed commonalities and beliefs in line with other American racial and ethnic groups, we also identified unique beliefs, such as familial influence, religious and cultural concerns regarding body wholeness and the dead, and underlying reasons for medical mistrust, such as a belief in a black market. The study's findings challenge the dominant educational and awareness campaigns about organ donation decision making that focus on individual autonomy and overlook the need for incorporating the specific content and message delivery needs of Asian Americans. This study is the first to explore attitudes and knowledge about posthumous organ donation among US Asian American populations in at least a decade.
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Mogul DB, Lee J, Purnell TS, Massie AB, Ishaque T, Segev DL, Bridges JF. Barriers to access in pediatric living-donor liver transplantation. Pediatr Transplant 2019; 23:e13513. [PMID: 31215155 PMCID: PMC9421564 DOI: 10.1111/petr.13513] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 05/09/2019] [Accepted: 05/12/2019] [Indexed: 12/13/2022]
Abstract
Children receiving a LDLT have superior post-transplant outcomes, but this procedure is only used for 10% of transplant recipients. Better understanding about barriers toward LDLT and the sociodemographic characteristics that influence these underlying mechanisms would help to inform strategies to increase its use. We conducted an online, anonymous survey of parents/caregivers for children awaiting, or have received, a liver transplant regarding their knowledge and attitudes about LDLT. The survey was completed by 217 respondents. While 97% of respondents understood an individual could donate a portion of their liver, only 72% knew the steps in evaluation, and 69% understood the donor surgery was covered by the recipient's insurance. Individuals with public insurance were less likely than those with private insurance to know the steps for LDLT evaluation (44% vs 82%; P < 0.001). Respondents with public insurance were less likely to know someone that had been a living donor (44% vs 56%; P = 0.005) as were individuals without a college degree (64% vs 85%; P = 0.007). Nearly all respondents generally trusted their healthcare team. Among respondents, 82% believed they were well-informed about LDLT but individuals with public insurance were significantly less likely to feel well-informed (67% vs 87%; P = 0.03) and to understand how donor surgery might impact donor work/time off (44% vs 81%; P = 0.001). Substantial gaps exist in parental understanding about LDLT, including its evaluation, potential benefits, and complications. Greater emphasis on addressing these barriers, especially to individuals with fewer resources, will be helpful to expand the use of LDLT.
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Affiliation(s)
- Douglas B. Mogul
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joy Lee
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN
| | - Tanjala S. Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Tanveen Ishaque
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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Impact of Race and Ethnicity on Outcomes for Children Waitlisted for Pediatric Liver Transplantation. J Pediatr Gastroenterol Nutr 2018; 66:436-441. [PMID: 29045352 PMCID: PMC5825240 DOI: 10.1097/mpg.0000000000001793] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE African Americans and other minorities are known to face barriers to health care influencing their access to organ transplantation but it is not known whether these barriers exist among pediatric liver transplant waitlist candidates. We sought to determine whether outcomes on the waitlist (ie, mortality, deceased donor liver transplantation [DDLT], and living-donor liver transplantation [LDLT]) varied by race/ethnicity. METHODS National registry data were studied to estimate the race/ethnicity-specific risk of waitlist mortality, DDLT and LDLT in children (<18 years) waitlisted between March 2002 and March 2015. RESULTS There was no evidence of racial/ethnic disparities in waitlist mortality. Compared to Caucasians, LDLT varied by race/ethnicity, with only 6.7% African Americans and 10.3% Hispanic children receiving LDLT compared with 12.4% Caucasian, 13.3% Asian, and 9.4% mix/other children. In an adjusted Cox proportional hazards model, African Americans were half as likely as Caucasians to use LDLT (hazard ratio [HR]: 0.410.550.73) but had similar use of DDLT (HR: 0.981.061.16). In a model that considered mortality, DDLT, and LDLT as competing risks, African Americans had significantly reduced incidence of LDLT (subhazard ratio [sHR]: 0.410.560.75) compared to Caucasians, but increased use of DDLT (sHR: 1.061.161.26). CONCLUSIONS Compared to Caucasian children, African-American children are less likely to use LDLT but have higher rates of DDLT and similar survival on the waitlist. Additional research is necessary to understand the clinical and socioeconomic factors contributing to lower utilization of LDLT among African-American children awaiting transplantation.
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Employment 12 months after kidney transplantation: An in-depth bio-psycho-social analysis of the Swiss Transplant Cohort. PLoS One 2017; 12:e0175161. [PMID: 28448501 PMCID: PMC5407833 DOI: 10.1371/journal.pone.0175161] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 03/21/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Return to work with or after a chronic disease is a dynamic process influenced by a variety of interactions between personal, work, societal and medical resources or constraints. The aim of this study was to identify predictors for employment 12 months after transplantation in kidney patients, applying a bio-psycho-social model. METHODS All kidney patients followed in the Swiss Transplant Cohort between May 2008 and December 2012, aged 18 to 65 were assessed before, 6 and 12 months after transplantation. RESULTS Of the 689 included patients, 56.2% worked 12 months post- transplantation compared to 58.9% pre-transplantation. Age, education, self-perceived health (6 months post- transplantation), pre- transplantation employment and receiving an organ from a living donor are significant predictors of employment post- transplantation. Moreover, while self-perceived health increased post- transplantation, depression score decreased only among those employed 12 months post- transplantation. Pre- transplantation employment status was the main predictor for post- transplantation employment (OR = 18.6) and was associated with sex, age, education, depression and duration of dialysis. An organ from a living donor (42.1%) was more frequent in younger patients, with higher education, no diabetes and shorter waiting time to surgery. CONCLUSION Transplantation did not increase employment in end-stage kidney disease patients but helped maintaining employment. Pre-transplantation employment has been confirmed to be the most important predictor of post-transplantation employment. Furthermore, socio-demographic and individual factors predicted directly and indirectly the post-transplantation employment status. With living donor, an additional predictor linked to social factors and the medical procedure has been identified.
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Gordon EJ. Culturally Competent Strategies for Increasing Knowledge of Live Kidney Donation in the Hispanic Community. CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0136-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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