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Sierra L, Marenco-Flores A, Barba R, Goyes D, Ferrigno B, Diaz W, Medina-Morales E, Saberi B, Patwardhan VR, Bonder A. Influence of socioeconomic factors on liver transplant survival outcomes in patients with autoimmune liver disease in the United States. Ann Hepatol 2024; 29:101283. [PMID: 38151060 DOI: 10.1016/j.aohep.2023.101283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/15/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION AND OBJECTIVES Autoimmune liver diseases (AILDs): autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC) have different survival outcomes after liver transplant (LT). Outcomes are influenced by factors including disease burden, medical comorbidities, and socioeconomic variables. MATERIALS AND METHODS Using the United Network for Organ Sharing database (UNOS), we identified 13,702 patients with AILDs listed for LT between 2002 and 2021. Outcomes of interest were waitlist removal, post-LT patient survival, and post- LT graft survival. A stepwise multivariate analysis was performed adjusting for transplant recipient gender, race, diabetes mellitus, model for end-stage liver disease (MELD) score, and additional social determinants including the presence of education, reliance on public insurance, working for income, and U.S. citizenship status. RESULTS Lack of college education and having public insurance increased the risk of waitlist removal (HR, 1.13; 95 % CI, 1.05-1.23, and HR, 1.09; 95 % CI, 1.00-1.18; respectively), and negatively influenced post-LT patient survival (HR, 1.16; 95 % CI, 1.06-1.26, and HR, 1.15; 95 % CI, 1.06-1.25; respectively) and graft survival (HR, 1.13; 95 % CI, 1.05-1.23, and HR, 1.15; 95 % CI, 1.06-1.25; respectively). Not working for income proved to have the greatest detrimental impact on both patient survival (HR, 1.41; 95 % CI, 1.24-1.6) and graft survival (HR, 1.21; 95 % CI, 1.09-1.35). CONCLUSIONS Our study highlights that lack of college education and public insurance have a detrimental impact on waitlist mortality, patient survival, and graft survival. Not working for income negatively affects post-LT survival outcomes. Not having U.S. citizenship does not affect survival outcomes in AILDs patients.
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Affiliation(s)
- Leandro Sierra
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Ana Marenco-Flores
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Romelia Barba
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Daniela Goyes
- Division of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520, USA
| | - Bryan Ferrigno
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Wilfor Diaz
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Esli Medina-Morales
- Department of Medicine, Rutgers New Jersey Medical School, Medical Science Building, 185 South Orange Avenue, Newark, NJ 07103, USA
| | - Behnam Saberi
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Vilas R Patwardhan
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Alan Bonder
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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2
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Lim WH, Yong JN, Ong CEY, Ng CH, Tan DJH, Zeng RW, Chung CH, Kaewdech A, Chee D, Tseng M, Wijarnpreecha K, Syn N, Bonney GK, Kow A, Huang DQ, Noureddin M, Muthiah M, Tan E, Siddiqui MS. Ethnic disparities in waitlist outcomes of patients with nonalcoholic steatohepatitis listed for liver transplantation in the US. Liver Transpl 2023; 29:1181-1191. [PMID: 37039547 DOI: 10.1097/lvt.0000000000000148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/06/2023] [Indexed: 04/12/2023]
Abstract
NASH is the fastest-growing cause of liver cirrhosis and is the leading indication for liver transplantation (LT). However, significant racial and ethnic disparities in waitlist outcomes and LT allocation may unfairly disadvantage minorities. Our aim was to characterize racial and ethnic disparities in waitlist mortality and transplantation probability among patients with NASH. This is a retrospective analysis of the United Network for Organ Sharing registry data of LT candidates from January 1, 2000 to December 31, 2021. Outcomes analysis was performed using competing risk analysis with the Fine and Gray model. The multivariable adjustment was conducted, and mixed-effect regression was used to compare the model for end-stage liver disease scores at listing and removal. Of 18,562 patients with NASH cirrhosis, there were 14,834 non-Hispanic Whites, 349 African Americans, 2798 Hispanics, 312 Asians, and 269 of other races/ethnicities; African American (effect size: 2.307, 95% CI: 1.561-3.053, and p < 0.001) and Hispanic (effect size: 0.332, 95% CI: 0.028-0.637, p = 0.032) patients were found to have a significantly higher model for end-stage liver disease scores at the time of listing than non-Hispanic Whites. African Americans had a higher probability of receiving LT relative to non-Hispanic Whites (subdistribution HR: 1.211, 95% CI: 1.051-1.396, and p = 0.008). However, Hispanic race/ethnicity was associated with a lower transplantation probability (subdistribution HR: 0.793, 95% CI: 0.747-0.842, and p < 0.001) and increased waitlist mortality (subdistribution HR: 1.173, CI: 1.052-1.308, and p = 0.004) compared with non-Hispanic Whites. There are significant racial and ethnic disparities in waitlist outcomes of patients with NASH in the US. Hispanic patients are less likely to receive LT and more likely to die while on the waitlist compared with non-Hispanic Whites despite being listed with a lower model for end-stage liver disease scores.
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Affiliation(s)
- Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Christen En Ya Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Cheng Han Ng
- Department of Medicine, Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Charlotte Hui Chung
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Apichat Kaewdech
- Department of Medicine, Division of Internal Medicine, Gastroenterology and Hepatology Unit, Prince of Songkla University, Hat Yai, Thailand
| | - Douglas Chee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Medicine, Division of Gastroenterology and Hepatology, National University Hospital, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Michael Tseng
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Karn Wijarnpreecha
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Arizona College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Glenn K Bonney
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, National University Hospital Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Alfred Kow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, National University Hospital Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Medicine, Division of Gastroenterology and Hepatology, National University Hospital, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | | | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Medicine, Division of Gastroenterology and Hepatology, National University Hospital, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Eunice Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Medicine, Division of Gastroenterology and Hepatology, National University Hospital, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Mohammad Shadab Siddiqui
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
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3
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Kilani Y, Kamal SAF, Vikash F, Vikash S, Aldiabat M, Alsakarneh S, Aljabiri Y, Sohail H, Kumar V, Numan L, Al Khalloufi K. Racial Disparities in Liver Transplantation for Hepatocellular Carcinoma in the United States: An Update. Dig Dis Sci 2023; 68:4050-4059. [PMID: 37584869 DOI: 10.1007/s10620-023-08084-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/07/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Previous studies have demonstrated a disparity in liver transplantation (LT) for hepatocellular carcinoma (HCC) among races in the United States (U.S.). AIMS We aimed to update the literature on the odds, trends, and complications of LT in the treatment of hepatocellular carcinoma (HCC), among individuals of different racial backgrounds. METHODS This is a nationwide study of adult individuals admitted for LT with a primary diagnosis of HCC. Using weighted data from the National Inpatient Sample (NIS) database, we compared the odds of LT among different races from 2016 to 2020, using a multivariate regression analysis. We further assessed the trends and outcomes of LT among races. RESULTS A total of 112,110 adult were hospitalized with a primary diagnosis of HCC. 3020 underwent LT. When compared to Whites, the likelihood of undergoing LT for HCC was significantly reduced in Blacks (OR = 0.60, 95% CI = 0.46-0.78). Further, Blacks had increased mortality rates (7% in Blacks vs. 1% in Whites, p < 0.001), sepsis (11% in Blacks vs. 3% in Whites, p = 0.015), and acute kidney injury (AKI) (54% in Blacks vs. 31% in Whites, p < 0.001) following LT. CONCLUSIONS Individuals identifying as Blacks were less likely to undergo LT for HCC, and more likely to develop complications. Further initiatives are warranted to mitigate the existing disparities among racial groups.
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Affiliation(s)
- Yassine Kilani
- Department of Medicine, Lincoln Medical Center/Weill Cornell Medicine, New York, NY, USA.
| | | | - Fnu Vikash
- Department of Medicine, Jacobi Medical Center, New York, NY, USA
| | - Sindhu Vikash
- Department of Medicine, Jacobi Medical Center, New York, NY, USA
| | | | - Saqr Alsakarneh
- Department of Medicine, University of Missouri, Kansas City, MO, USA
| | - Yazan Aljabiri
- Department of Medicine, Lincoln Medical Center/Weill Cornell Medicine, New York, NY, USA
| | - Haris Sohail
- Department of Medicine, Lincoln Medical Center/Weill Cornell Medicine, New York, NY, USA
| | - Vikash Kumar
- Department of Medicine, Brooklyn Hospital Center, New York, NY, USA
| | - Laith Numan
- Department of Gastroenterology, Saint Louis University, Saint Louis, MO, USA
| | - Kawtar Al Khalloufi
- Department of Transplant Hepatology, University of South Florida, Tampa, FL, USA
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Recipient Age Predicts 20-Year Survival in Pediatric Liver Transplant. Can J Gastroenterol Hepatol 2022; 2022:1466602. [PMID: 36164664 PMCID: PMC9509270 DOI: 10.1155/2022/1466602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/12/2022] [Accepted: 08/25/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Pediatric liver transplant recipients have demonstrated excellent long-term survival. The purpose of this analysis is to investigate factors associated with 20-year survival to identify areas for improvement in patient care. METHODS Kaplan-Meier with log-rank test as well as univariate and multivariate logistic regression methods were used to retrospectively analyze 4,312 liver transplant recipients under the age of 18 between September 30, 1987 and March 9, 1998. Our primary endpoint was 20-year survival among one-year survival. RESULTS Logistic regression analysis identified recipient age as a significant risk factor, with recipients below 5 years old having a higher 20-year survival rate (p < 0.001). A preoperative primary diagnosis of a metabolic dysfunction was found to be protective compared to other diagnoses (OR 1.64, CI 1.20-2.25). African-American ethnicity (OR 0.71, CI 0.58-0.87) was also found to be a risk factor for mortality. Technical variant allografts (neither living donor nor cadaveric) were not associated with increased or decreased rates of 20-year survival. CONCLUSIONS Our analysis suggests that long-term survival is inversely correlated with recipient age following pediatric liver transplant. If validated with further studies, this conclusion may have profound implications on the timing of pediatric liver transplantation.
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Mansour MM, Fard D, Basida SD, Obeidat AE, Darweesh M, Mahfouz R, Ahmad A. Disparities in Social Determinants of Health Among Patients Receiving Liver Transplant: Analysis of the National Inpatient Sample From 2016 to 2019. Cureus 2022; 14:e26567. [PMID: 35936191 PMCID: PMC9350951 DOI: 10.7759/cureus.26567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 11/05/2022] Open
Abstract
Background Liver transplantation is the life-saving standard of care for those with end-stage liver disease. Unfortunately, many patients on the liver transplant list die waiting. Several studies have demonstrated significant differences based on disparities in race, gender, and multiple socioeconomic factors. We sought to evaluate recent disparities among patients receiving liver transplants using the latest available data from the National Inpatient Sample (NIS), the largest publicly available inpatient care database in the United States. Methods We performed an analysis of discharge data from the NIS between 2016 and 2019. We identified adult patients with chronic liver disease who underwent a liver transplant using the International Classification of Diseases, 10th revision (ICD-10) codes. Multivariate logistic regression was used to adjust for differences in race, gender, socioeconomic status, and comorbidities among those who received a liver transplant. Results A total of 24,595 liver transplants were performed over the study period. Female gender was independently associated with decreased transplant rates (adjusted odds ratio (AOR) 0.83, 95% confidence interval (CI), 0.78-0.89, P < 0.001). Compared to White patients, Black patients had decreased transplant rates (AOR 0.86, 95% CI, 0.75-0.99, P = 0.034), as did Native Americans (AOR 0.64; 95% CI, 0.42-0.97, P = 0.035). Hispanics and Asian Americans had increased rates of liver transplantation (AOR 1.16, 95% CI 1.02-1.32, P = 0.022, and 1.36, 95% CI 1.11-1.67, P = 0.003; respectively). The increase in income quartile was associated with an incremental increase in transplant rates. Additionally, patients with private insurance had much higher transplant rates compared to those with Medicare (AOR 2.50, 95% CI 2.31-2.70, P < 0.001) while patients without insurance had the lowest rates of transplantation (AOR 0.18, 95% CI 0.12-0.28, P < 0.001). Conclusions Our analysis demonstrates that race, gender, and other social determinants of health have significant impacts on the likelihood of receiving a liver transplant. Our study, on a national level, confirms previously described disparities in receiving liver transplantation. Patient-level studies are needed to better understand how these variables translate into differing liver transplantation rates.
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6
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Keeling SS, McDonald MF, Anand A, Handing GE, Prather LL, Christmann CR, Jalal PK, Kanwal F, Cholankeril G, Goss JA, Rana A. Significant improvements, but consistent disparities in survival for African Americans after liver transplantation. Clin Transplant 2022; 36:e14646. [PMID: 35304775 PMCID: PMC9310351 DOI: 10.1111/ctr.14646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 02/20/2022] [Accepted: 03/06/2022] [Indexed: 11/28/2022]
Abstract
Despite improvements in survival across races in the past 20 years, African Americans have worse liver transplant outcomes after orthotopic liver transplantation (OLT). This study aims at quantifying the change in disparities between African Americans and other races in survival after OLT. We retrospectively analyzed the United Network for Organ Sharing (UNOS) database for patient data for candidates who received a liver transplant between January 1, 2007 and December 31, 2017. Multivariate Cox proportional hazards regression indicated similar decreases in mortality over time for each race with a decrease in mortality for African Americans: 2010-2012 (HR = .930), 2012-2015 (HR = .882), and 2015-2017 (HR = .883) when compared to 2007-2010. Risk of mortality for African Americans compared to Caucasians varied across the 4 eras: 2007-2010 (HR = 1.083), 2010-2012 (HR = 1.090), 2012-2015 (HR = 1.070), and 2015-2017 (HR = 1.125). While African Americans have seen increases in survival in the past decade, a similar increase in survival for other races leaves a significant survival disparity in African Americans.
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Affiliation(s)
| | - Malcolm F. McDonald
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Adrish Anand
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Greta E. Handing
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Lyndsey L. Prather
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | | | - Prasun K. Jalal
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Fasiha Kanwal
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - George Cholankeril
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - John A. Goss
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Abbas Rana
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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7
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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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8
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Goyes D, Nsubuga JP, Medina-Morales E, Barba R, Patwardhan V, Saberi B, Fricker Z, Bonder A. Race/Ethnicity Is Not Independently Associated with Risk of Adverse Waitlist Removal among Patients with HCC Exception Points. J Clin Med 2021; 10:jcm10245826. [PMID: 34945122 PMCID: PMC8704844 DOI: 10.3390/jcm10245826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Since 2015, exception points have been awarded to appropriate candidates after six months of waitlist time to allow more equitable access to liver transplants regardless of hepatocellular carcinoma status. However, it remains unknown whether racial disparities in outcomes among waitlisted patients remain after the introduction of a 6-month waiting period for exception points. (2) Methods: Using the United Network for Organ Sharing database, we identified 2311 patients diagnosed with hepatocellular carcinoma listed for liver transplant who received exception points from 2015 to 2019. The outcome of interest was waitlist survival defined as the composite outcome of death or removal for clinical deterioration. Competing risk analysis was used to identify factors associated with death or removal for clinical deterioration. The final model adjusted for age, sex, race/ethnicity, blood type, diabetes, obesity, laboratory MELD score, tumor size, AFP, locoregional therapies, UNOS region, and college education. (3) Results: No difference was found in the risk of adverse waitlist removal among ethnic/racial groups.
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Affiliation(s)
- Daniela Goyes
- Department of Medicine, Loyola Medicine—MacNeal Hospital, Berwyn, IL 60402, USA;
| | - John Paul Nsubuga
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA;
| | - Esli Medina-Morales
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (E.M.-M.); (R.B.); (V.P.); (B.S.); (Z.F.)
| | - Romelia Barba
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (E.M.-M.); (R.B.); (V.P.); (B.S.); (Z.F.)
| | - Vilas Patwardhan
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (E.M.-M.); (R.B.); (V.P.); (B.S.); (Z.F.)
| | - Behnam Saberi
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (E.M.-M.); (R.B.); (V.P.); (B.S.); (Z.F.)
| | - Zachary Fricker
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (E.M.-M.); (R.B.); (V.P.); (B.S.); (Z.F.)
| | - Alan Bonder
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (E.M.-M.); (R.B.); (V.P.); (B.S.); (Z.F.)
- Correspondence:
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9
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Mazumder NR, Simpson D. Disparities persist for Black liver transplant recipients despite years of data collection: What is missing? Am J Transplant 2021; 21:3821-3822. [PMID: 34523243 DOI: 10.1111/ajt.16844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/05/2021] [Accepted: 09/10/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Nikhilesh R Mazumder
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA.,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Dinee Simpson
- Division of Transplant, Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
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10
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Yuan Q, Haque O, Yeh H, Markmann JF, Dageforde LA. The impact of race and comorbid conditions on adult liver transplant outcomes in obese recipients. Transpl Int 2021; 34:2834-2845. [PMID: 34580936 DOI: 10.1111/tri.14125] [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: 06/01/2021] [Revised: 08/09/2021] [Accepted: 09/10/2021] [Indexed: 11/28/2022]
Abstract
Many prior studies comparing liver transplant outcomes between obese and nonobese recipients found no significant differences in survival. However, obesity is intrinsically associated with demographic factors such as race and comorbidities. Thus, this work aimed to analyze the effects of obesity, in conjunction with these factors, on liver transplant outcomes. OPTN data was analyzed to identify adult-only, first-time liver transplants between 1995 and 2019. Obesity was defined by the CDC obesity classification. Race, insurance status, age, and comorbidities were analyzed together with patient survival and graft survival using a multivariable Cox Proportional-Hazards model and long-term survival with Kaplan-Meier curves. The multivariable models found that being black, older than 50 years, having diabetes, or having nonprivate insurance were all risk factors for both patient survival and graft survival after liver transplant. Adjusting for obesity class, black recipients had a 20% lower patient survival and 23% lower graft survival compared with nonblack recipients. Survival curves verified that obese black liver transplant recipients had poorer long-term patient survival and graft survival compared with both obese nonblack and nonobese recipients. In conclusion, obesity compounds known factors associated with poor outcomes after liver transplantation. Further work is critical to understand why these discrepancies persist.
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Affiliation(s)
- Qing Yuan
- Department of Urology, Chinese PLA General Hospital, Beijing, China.,Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Omar Haque
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Surgery, Beth Issrael Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Shriners Hospitals for Children, Boston, MA, USA
| | - Heidi Yeh
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - James F Markmann
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Leigh Anne Dageforde
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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11
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Rosenblatt R, Wahid N, Halazun KJ, Kaplan A, Jesudian A, Lucero C, Lee J, Dove L, Fox A, Verna E, Samstein B, Fortune BE, Brown RS. Black Patients Have Unequal Access to Listing for Liver Transplantation in the United States. Hepatology 2021; 74:1523-1532. [PMID: 33779992 DOI: 10.1002/hep.31837] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/27/2021] [Accepted: 03/17/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS The Model for End-Stage Liver Disease score may have eliminated racial disparities on the waitlist for liver transplantation (LT), but disparities prior to waitlist placement have not been adequately quantified. We aimed to analyze differences in patients who are listed for LT, undergo transplantation, and die from end-stage liver disease (ESLD), stratified by state and race/ethnicity. APPROACH AND RESULTS We analyzed two databases retrospectively, the Center for Disease Control Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) and the United Network for Organ Sharing (UNOS) databases, from 2014 to 2018. We included patients aged 25-64 years who had a primary cause of death of ESLD and were listed for transplant in the CDC WONDER or UNOS database. Our primary outcome was the ratio of listing for LT to death from ESLD-listing to death ratio (LDR). Our secondary outcome was the transplant to listing and transplant to death ratios. Chi-squared and multivariable linear regression evaluated for differences between races/ethnicities. There were 135,367 patients who died of ESLD, 54,734 patients who were listed for transplant, and 26,571 who underwent transplant. Patients were mostly male and White. The national LDR was 0.40, significantly lowest in Black patients (0.30), P < 0.001. The national transplant to listing ratio was 0.48, highest in Black patients (0.53), P < 0.01. The national transplant to death ratio was 0.20, lowest in Black patients (0.16), P < 0.001. States that had an above-mean LDR had a lower transplant to listing ratio but a higher transplant to death ratio. Multivariable analysis confirmed that Black race is significantly associated with a lower LDR and transplant to death ratio. CONCLUSIONS Black patients face a disparity in access to LT due to low listing rates for transplant relative to deaths from ESLD.
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Affiliation(s)
- Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
| | - Nabeel Wahid
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Karim J Halazun
- Center for Liver Disease and Transplantation, New York, NY.,Liver Transplant and HPB Surgery, Weill Cornell Medical College, New York, NY
| | - Alyson Kaplan
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Arun Jesudian
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
| | - Catherine Lucero
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
| | - Jihui Lee
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Lorna Dove
- Center for Liver Disease and Transplantation, New York, NY.,Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, NY
| | - Alyson Fox
- Center for Liver Disease and Transplantation, New York, NY.,Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, NY
| | - Elizabeth Verna
- Center for Liver Disease and Transplantation, New York, NY.,Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, NY
| | - Benjamin Samstein
- Center for Liver Disease and Transplantation, New York, NY.,Liver Transplant and HPB Surgery, Weill Cornell Medical College, New York, NY
| | - Brett E Fortune
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
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12
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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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13
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Mazumder NR, Simpson D, Atiemo K, Jackson K, Zhao L, Daud A, Kho A, Gabra LG, Caicedo JC, Levitsky J, Ladner DP. Black Patients With Cirrhosis Have Higher Mortality and Lower Transplant Rates: Results From a Metropolitan Cohort Study. Hepatology 2021; 74:926-936. [PMID: 34128254 DOI: 10.1002/hep.31742] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/30/2020] [Accepted: 01/19/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Estimates of racial disparity in cirrhosis have been limited by lack of large-scale, longitudinal data, which track patients from diagnosis to death and/or transplant. APPROACH AND RESULTS We analyzed a large, metropolitan, population-based electronic health record data set from seven large health systems linked to the state death registry and the national transplant database. Multivariate competing risk analyses, adjusted for sex, age, insurance status, Elixhauser score, etiology of cirrhosis, HCC, portal hypertensive complication, and Model for End-Stage Liver Disease-Sodium (MELD-Na), examined the relationship between race, transplant, and cause of death as defined by blinded death certificate review. During the study period, 11,277 patients met inclusion criteria, of whom 2,498 (22.2%) identified as Black. Compared to White patients, Black patients had similar age, sex, MELD-Na, and proportion of alcohol-associated liver disease, but higher comorbidity burden, lower rates of private insurance, and lower rates of portal hypertensive complications. Compared to White patients, Black patients had the highest rate all-cause mortality and non-liver-related death and were less likely to be listed or transplanted (P < 0.001 for all). In multivariate competing risk analysis, Black patients had a 26% increased hazard of liver-related death (subdistribution HR, 1.26; 95% CI, [1.15-1.38]; P < 0.001). CONCLUSIONS Black patients with cirrhosis have discordant outcomes. Further research is needed to determine how to address these real disparities in the field of hepatology.
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Affiliation(s)
- Nikhilesh R Mazumder
- Department of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIL.,Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL
| | - Dinee Simpson
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Division of TransplantDepartment of SurgeryNorthwestern MedicineChicagoIL
| | - Kofi Atiemo
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Tulane Abdominal Transplant InstituteDepartment of SurgeryTulane University School of MedicineNew OrleansLA
| | - Kathryn Jackson
- Institute for Public Health and Medicine-Center for Health Information PartnershipsNorthwestern University, Feinberg School of MedicineChicagoIL
| | - Lihui Zhao
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Department of Preventative MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Amna Daud
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL
| | - Abel Kho
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Institute for Public Health and Medicine-Center for Health Information PartnershipsNorthwestern University, Feinberg School of MedicineChicagoIL
| | - Lauren G Gabra
- Feinberg School of MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Juan C Caicedo
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Division of TransplantDepartment of SurgeryNorthwestern MedicineChicagoIL
| | - Josh Levitsky
- Department of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIL.,Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL
| | - Daniela P Ladner
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Division of TransplantDepartment of SurgeryNorthwestern MedicineChicagoIL
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14
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Asemota J, Oladunjoye O, Babalola A, Nwosu U, Liu PHS, Oladunjoye AO, Castro-Webb N, Miksad RA. Comparison of Hepatocellular Carcinoma in Hispanic and Non-Hispanic Patients. Cureus 2021; 13:e14884. [PMID: 34104609 PMCID: PMC8180179 DOI: 10.7759/cureus.14884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the fastest growing cancer in the United States. Studies have shown that compared to Blacks and non-Hispanic Whites, Hispanics have a higher HCC incidence and mortality rate. Most studies investigating HCC in Hispanics have been conducted utilizing data largely from the Western and Southern United States. These findings may, however, not be highly representative of Hispanics in the Northeast, given the nonhomogenous distribution and diversity of Hispanics across the United States. METHODS Some 148 HCC patients diagnosed between 1996 and 2012 were identified from a tertiary center in the northeastern United States. Hispanic patients were randomly matched to non-Hispanic White patients by year of diagnosis. Patient characteristics, HCC risk factors, treatment, and outcome were recorded. A Kaplan-Meier (KM) plot with log-rank tests was used for survival analysis. RESULTS Compared to non-Hispanic White patients (n=89), Hispanic HCC patients (n=59) were more likely to have chronic hepatitis C infection (69.5% vs. 38.2%, p < 0.01), alcoholic liver disease (37.3% vs. 21.4%, p = 0.04) and were less likely to have chronic hepatitis B infection (6.8% vs. 24.7%, p = 0.01), and private insurance (37.3% vs. 57.3%, p = 0.02). Hispanics were more likely to be diagnosed with an earlier stage disease (Barcelona Clinic Liver Cancer, BCLC stages A and B) compared to non-Hispanic patients (71.7% vs. 36.8%, p < 0.01) and were more likely to receive locoregional treatment. Although Hispanics trended towards improved overall survival, this finding did not hold when stratified by the BCLC stage. CONCLUSION Risk factors for HCC in the northeastern Hispanic population are like those found among Hispanics in other US regions. Other research suggests Hispanics are at increased risk for hepatic injury and HCC. However, HCC in this northeastern Hispanic population appears to be less aggressive (earlier stage and trend towards better overall survival) than non-Hispanics. Further research may be needed to identify potential differences by ethnic group for HCC risk factors, presentation, and outcomes.
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Affiliation(s)
- Joseph Asemota
- Internal Medicine, Howard University Hospital, Washington DC, USA
- Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
- Clinical Anatomy, St. George's University School of Medicine, True Blue, GRD
| | - Olubunmi Oladunjoye
- Internal Medicine, Tower Health-Reading Hospital, West Reading, USA
- Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Atinuke Babalola
- Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Ugonna Nwosu
- Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Po-Hong S Liu
- Internal Medicine, UT Southwestern Medical Center, Dallas, USA
- Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | | | - Nelsy Castro-Webb
- Epidemiology and Public Health, Boston University School of Medicine, Boston, USA
- Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Rebecca A Miksad
- Medicine, Boston University School of Medicine, Boston, USA
- Oncology, Flatiron Health, New York, USA
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15
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Racial/Ethnic Disparities in Access and Outcomes of Simultaneous Liver-Kidney Transplant Among Liver Transplant Candidates With Renal Dysfunction in the United States. Transplantation 2020; 103:1663-1674. [PMID: 30720678 DOI: 10.1097/tp.0000000000002574] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Since the Model for End-stage Liver Disease (MELD) allocation system was implemented, the proportion of simultaneous liver-kidney transplantation (SLKT) has increased significantly. However, whether racial/ethnic disparities exist in access to SLKT and post-SLKT survival remains understudied. METHODS A retrospective cohort of patients aged ≥18 years with renal dysfunction on the liver transplant (LT) waiting list was obtained from Organ Procurement and Transplantation Network. Renal dysfunction was defined as estimated glomerular filtration rate <60 mL/min/1.73 m at listing for LT. Multilevel time-to-competing-events regression adjusting for center effect was used to examine the likelihood of receiving SLKT. Inverse probability of treatment weighted survival analyses were used to analyze posttransplant mortality outcomes. RESULTS For patients with renal dysfunction at listing for LT, not listed for simultaneous kidney transplant, non-Hispanic black (NHB) and Hispanic patients were more likely to receive SLKT than non-Hispanic white (NHW) patients (NHB: multivariable-adjusted hazard ratio [aHR] 2.57; 95% confidence interval [CI], 1.42-4.65; Hispanic: aHR, 2.03; 95% CI, 1.14-3.60). For post-SLKT outcomes, compared to NHW patients, NHB patients had a lower mortality risk before 24 months (aHR, 0.80; 95% CI, 0.65-0.97) but had a higher mortality risk (aHR, 2.00; 95% CI, 1.59-2.55) afterward; in contrast, Hispanic patients had a lower overall mortality risk than NHW patients (aHR, 0.61; 95% CI, 0.51-0.74). CONCLUSIONS In the MELD era, racial/ethnic differences exist in access and survival of SLKT for patients with renal dysfunction at listing for LT. Future studies are warranted to examine whether these differences remain in the post-SLK allocation policy era.
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16
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A Comprehensive Analysis of Liver Transplantation Outcomes Among Ethnic Minorities in the United States. J Clin Gastroenterol 2020; 54:263-270. [PMID: 31169758 DOI: 10.1097/mcg.0000000000001236] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOALS The aim of this study was to perform a comprehensive assessment of liver transplant (LT) outcomes among US adults with a specific focus on understanding race/ethnicity-specific disparities. BACKGROUND Despite improvements in the liver allocation and LT-related care, disparities in LT outcomes persist. STUDY Using data from the 2005 to 2016 United Networks for Organ Sharing LT registry, we evaluated waitlist survival, probability of receiving LT, and post-LT survival among US adults stratified by race/ethnicity and liver disease etiology. Kaplan-Meier methods evaluated unadjusted waitlist and post-LT outcomes, and multivariate regression models evaluated adjusted waitlist and post-LT outcomes. RESULTS Among 88,542 listed for LT patients (41.3% hepatitis C virus, 25.3% alcoholic liver disease, 22.3% nonalcoholic steatohepatitis, 11.1% hepatitis C virus/alcoholic liver disease), significant race/ethnicity-specific disparities were observed. Compared with non-Hispanic whites, Hispanics had a significantly lower risk of waitlist death [hazard ratio (HR)=0.84, 95% confidence interval (CI): 0.79-0.90, P<0.001]. Compared with non-Hispanic whites, significantly lower likelihood of receiving LT was observed in African Americans (HR=0.94, 95% CI: 0.91-0.98, P<0.001), Hispanics (HR=0.70, 95% CI: 0.68-0.73, P<0.001) and Asians (HR=0.74, 95% CI: 0.69-0.80, P<0.001). Compared with non-Hispanic whites, African Americans had a significantly higher risk of 5-year post-LT death (HR=1.31, 95% CI: 1.23-1.39, P<0.001). CONCLUSION Among US adults awaiting LT, significant race/ethnicity-specific disparities in LT outcomes were observed. Despite evaluating an era after implementation of the Model for End-Stage Liver Disease, ethnic minorities continue to demonstrate a lower probability of receiving LT, and significantly higher risk of death post-LT in African Americans.
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17
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Jesse MT, Abouljoud M, Goldstein ED, Rebhan N, Ho CX, Macaulay T, Bebanic M, Shkokani L, Moonka D, Yoshida A. Racial disparities in patient selection for liver transplantation: An ongoing challenge. Clin Transplant 2019; 33:e13714. [PMID: 31532023 DOI: 10.1111/ctr.13714] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 09/03/2019] [Accepted: 09/07/2019] [Indexed: 01/14/2023]
Abstract
Ample evidence suggests continued racial disparities once listed for liver transplantation, though few studies examine disparities in the selection process for listing. The objective of this study, via retrospective chart review, was to determine whether listing for liver transplantation was influenced by socioeconomic status and race/ethnicity. We identified 1968 patients with end-stage liver disease who underwent evaluation at a large, Midwestern center from January 1, 2004 through December 31, 2012 (72.9% white, 19.6% black, and 7.5% other). Over half (54.6%) of evaluated patients were listed; the three most common reasons for not listing were medical contraindications (11.9%), patient expired during evaluation (7.0%), and psychosocial contraindications (5.9%). In multivariable logistic regressions (listed vs not listed), across the three racial categories, the odds of being listed were lower for alcohol-induced hepatitis (±hepatitis C), unmarried, more than one insurance, inadequate insurance, and lower annual household income quartile. Similar factors predicted time to transplant listing, including being identified as black race. Black race, even when adjusting for the above mentioned medical and socioeconomic factors, was associated with 26% lower odds of being listed and a longer time to listing decision compared to all other patients.
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Affiliation(s)
- Michelle T Jesse
- Transplant Institute, Henry Ford Health System, Detroit, MI.,Consultation-Liaison Psychiatry, Behavioral Health, Henry Ford Health System, Detroit, MI.,Center for Health Policy & Health Services Research, Henry Ford Health System, Detroit, MI
| | - Marwan Abouljoud
- Transplant Institute, Henry Ford Health System, Detroit, MI.,Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI
| | | | | | - Chuan-Xing Ho
- Transplant Institute, Henry Ford Health System, Detroit, MI
| | | | - Mubera Bebanic
- Transplant Institute, Henry Ford Health System, Detroit, MI
| | - Lina Shkokani
- Transplant Institute, Henry Ford Health System, Detroit, MI
| | - Dilip Moonka
- Transplant Institute, Henry Ford Health System, Detroit, MI.,Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, MI
| | - Atsushi Yoshida
- Transplant Institute, Henry Ford Health System, Detroit, MI.,Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI
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18
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Bodek D, Patel P, Ahlawat S, Orosz E, Nasereddin T, Pyrsopoulos N. Superior Performance of Teaching and Transplant Hospitals in the Management of Hepatic Encephalopathy from 2007 to 2014. J Clin Transl Hepatol 2018; 6:362-371. [PMID: 30637212 PMCID: PMC6328739 DOI: 10.14218/jcth.2017.00078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 09/05/2018] [Accepted: 10/03/2018] [Indexed: 12/04/2022] Open
Abstract
Background and Aims: Hepatic encephalopathy is a liver disease complication with significant mortality and costs. The aim of this study was to evaluate the relative performance of facilities based on their teaching status and transplant capability by correlating their connections to mortality, cost, and length of stay from 2007 to 2014. Methods: The Nationwide Inpatient Sample database was utilized to collect information on (USA) American patients admitted with a primary diagnosis of hepatic encephalopathy from 2007-2014. Hospitals were placed into one of four categories using their teaching and transplant status. Using regression analysis, mortality, length of stay and cost adjusted rate ratios were calculated. Results: The study revealed that teaching transplant centers had a mortality risk ratio of 0.783 (95% confidence interval (CI): 0.750-0.819, p < 0.001). Blacks had the highest mortality risk ratio, of 1.273 (95%CI: 1.217-1.331, p < 0.001). Furthermore, teaching transplant hospitals had a cost rate ratio of 1.226 (95%CI: 1.214-1.238, p < 0.001) and a length of stay rate ratio of 1.104 (95%CI: 1.093-1.115, p < 0.001). Conclusions: It appears that admission to transplant facilities for hepatic encephalopathy is associated with reduced mortality but increased costs and longer stay independent of transplantation. Moreover, factors impacting black mortality should also be examined more closely.
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Affiliation(s)
- Daniel Bodek
- Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
| | - Pavan Patel
- Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
| | - Sushil Ahlawat
- Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
| | - Evan Orosz
- Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
| | - Thayer Nasereddin
- Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
| | - Nikolaos Pyrsopoulos
- Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
- *Correspondence to: Nikolaos Pyrsopoulos, Rutgers New Jersey Medical School, University Hospital, MSB H538, 185 South Orange Avenue, Newark, NJ 07103, USA. Tel: +1-973-972-5252, Fax: +1-973-972-3144, E-mail:
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19
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Wen JW, Kohn MA, Wong R, Somsouk M, Khalili M, Maher J, Tana MM. Hospitalizations for Autoimmune Hepatitis Disproportionately Affect Black and Latino Americans. Am J Gastroenterol 2018; 113:243-253. [PMID: 29380822 PMCID: PMC6522224 DOI: 10.1038/ajg.2017.456] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 10/30/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The healthcare burden of autoimmune hepatitis (AIH) in the United States has not been characterized. We previously showed that AIH disproportionately affects people of color in a single hospital system. The current study aimed to determine whether the same disparity occurs nationwide. METHODS We analyzed hospitalizations with a primary discharge diagnosis corresponding to the ICD-9 code for AIH in the National Inpatient Sample between 2008 and 2012. For each racial/ethnic group, we calculated the AIH hospitalization rate per 100,000 population and per 100,000 all-cause hospitalizations, then calculated a risk ratio compared to the reference rate among whites. We used multivariable logistic regression models to assess for racial disparities and to identify predictors of in-hospital mortality during AIH hospitalizations. RESULTS The national rate of AIH hospitalization was 0.73 hospitalizations per 100,000 population. Blacks and Latinos were hospitalized for AIH at a rate 69% (P<0.001) and 20% higher (P<0.001) than whites, respectively. After controlling for age, gender, payer, residence, zip code income, region, and cirrhosis, black race was a statistically significant predictor for mortality during AIH hospitalizations (odds ratio (OR) 2.81, 95% confidence interval (CI) 1.43, 5.47). CONCLUSIONS Hospitalizations for AIH disproportionately affect black and Latino Americans. Black race is independently associated with higher odds of death during hospitalizations for AIH. This racial disparity may be related to biological, genetic, environmental, socioeconomic, and healthcare access and quality factors.
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Affiliation(s)
- Jason W. Wen
- Augusta University,Emory University School of Medicine, San Francisco, California, USA
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20
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Bezinover D, Reeder E, Aziz F, Saner F, McQuillan P, Kadry Z, Riley T, Guvakov D, Janicki PK. African Americans have a lower prevalence of portal vein thrombosis at the time of liver transplantation. HPB (Oxford) 2017; 19:620-628. [PMID: 28495438 DOI: 10.1016/j.hpb.2017.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 03/17/2017] [Accepted: 04/06/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perioperative vascular thrombotic events in patients undergoing liver transplantation (LT) are associated with significant morbidity and mortality. METHODS In this retrospective UNOS database analysis, we evaluated the prevalence of portal vein thrombosis (PVT) and factors contributing to PVT development in different ethnic groups. RESULTS Of the 47 953 LT performed between 2002 and 2015, we identified 3642 cases of PVT. African Americans (AA) had a significantly lower prevalence of PVT compared to other ethnic groups (p = 0.0001). Multivariable regression analysis confirmed that AA were less likely than other ethnicities to have PVT (OR = 0.6). AA cohort was more likely to have infectious or autoimmune causes of liver failure (OR = 1.6, 1.7 respectively) as well as higher creatinine and INR compared to other groups (OR = 1.6, 1.3 respectively). AA's were less likely to have encephalopathy, ascites, or variceal bleeding, which might indicate lower portal pressures. AA's were listed for LT later than other ethnicities and had both a lower functional status and higher MELD score at the time of registration. DISCUSSION AA's had a significantly lower prevalence of preoperative PVT despite having a greater number of factors predisposing to thrombosis. This predisposition should be considered before instituting perioperative antithrombotic therapy.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, 17033, PA, USA.
| | - Ethan Reeder
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, 17033, PA, USA
| | - Faisal Aziz
- Department of Surgery, Division of Vascular Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, 17033, PA, USA
| | - Fuat Saner
- Department of General, Visceral and Transplant Surgery, Essen University Medical Center, Hufeland 55, Essen, 45147, Germany
| | - Patrick McQuillan
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, 17033, PA, USA
| | - Zakiyah Kadry
- Department of Surgery, Division of Transplant Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, 17033, PA, USA
| | - Thomas Riley
- Department of Medicine, Division of Hepatology, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, 17033, PA, USA
| | - Dmitri Guvakov
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, 17033, PA, USA
| | - Piotr K Janicki
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, 17033, PA, USA
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Wilder JM, Oloruntoba OO, Muir AJ, Moylan CA. Role of patient factors, preferences, and distrust in health care and access to liver transplantation and organ donation. Liver Transpl 2016; 22:895-905. [PMID: 27027394 PMCID: PMC5567682 DOI: 10.1002/lt.24452] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 03/05/2016] [Accepted: 03/10/2016] [Indexed: 01/01/2023]
Abstract
Despite major improvements in access to liver transplantation (LT), disparities remain. Little is known about how distrust in medical care, patient preferences, and the origins shaping those preferences contribute to differences surrounding access. We performed a single-center, cross-sectional survey of adults with end-stage liver disease and compared responses between LT listed and nonlisted patients as well as by race. Questionnaires were administered to 109 patients (72 nonlisted; 37 listed) to assess demographics, health care system distrust (HCSD), religiosity, and factors influencing LT and organ donation (OD). We found that neither HCSD nor religiosity explained differences in access to LT in our population. Listed patients attained higher education levels and were more likely to be insured privately. This was also the case for white versus black patients. All patients reported wanting LT if recommended. However, nonlisted patients were significantly less likely to have discussed LT with their physician or to be referred to a transplant center. They were also much less likely to understand the process of LT. Fewer blacks were referred (44.4% versus 69.7%; P = 0.03) or went to the transplant center if referred (44.4% versus 71.1%; P = 0.02). Fewer black patients felt that minorities had as equal access to LT as whites (29.6% versus 57.3%; P < 0.001). For OD, there were more significant differences in preferences by race than listing status. More whites indicated OD status on their driver's license, and more blacks were likely to become an organ donor if approached by someone of the same cultural or ethnic background (P < 0.01). In conclusion, our analysis demonstrates persistent barriers to LT and OD. With improved patient and provider education and communication, many of these disparities could be successfully overcome. Liver Transplantation 22 895-905 2016 AASLD.
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Affiliation(s)
- Julius M. Wilder
- Division of Gastroenterology, Duke University Medical Center, Durham, NC,Duke Clinical Research Institute, Durham, NC
| | | | - Andrew J. Muir
- Division of Gastroenterology, Duke University Medical Center, Durham, NC,Duke Clinical Research Institute, Durham, NC
| | - Cynthia A. Moylan
- Division of Gastroenterology, Duke University Medical Center, Durham, NC,Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC
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Race/Ethnicity-specific Disparities in Hepatocellular Carcinoma Stage at Diagnosis and its Impact on Receipt of Curative Therapies. J Clin Gastroenterol 2016; 50:423-30. [PMID: 26583267 DOI: 10.1097/mcg.0000000000000448] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
GOALS To evaluate race/ethnicity-specific disparities in hepatocellular carcinoma (HCC) stage at diagnosis and how this impacts receiving curative therapies. BACKGROUND HCC is a leading cause of morbidity and mortality worldwide. The highest incidence of HCC is seen among ethnic minorities in the United States. STUDY Using the 2003-2011 Surveillance, Epidemiology, and End Results database and United Network of Organ Sharing, population-based registries for cancer and liver transplantation (LT) in the United States, race/ethnicity-specific cancer stage at diagnosis and treatment received among adults with HCC were evaluated. RESULTS Compared with non-Hispanic whites, blacks had significantly more advanced HCC at diagnosis [odds ratio (OR), 1.20; 95% confidence interval (CI), 1.10-1.30; P<0.001], whereas Asians were less likely to have advanced disease (OR, 0.87; CI, 0.80-0.94; P<0.001). Among patients with HCC meeting Milan criteria, Hispanics (OR, 0.64; 95% CI, 0.57-0.71; P<0.001) and blacks (OR, 0.67; 95% CI, 0.59-0.76; P<0.001) were significantly less likely to receive curative therapy (resection or LT), whereas Asians were more likely to receive curative therapy (OR, 1.22; 95% CI, 1.10-1.35; P<0.001) compared with non-Hispanic whites. However, Asians (OR, 0.49; 95% CI, 0.42-0.58; P<0.001) and Hispanics (OR, 0.51; 95% CI, 0.44-0.60; P<0.001) were less likely to receive LT. CONCLUSIONS Among US adults with HCC, blacks consistently had more advanced stage at diagnosis and lower rates of receiving treatment. After correcting for cancer stage and evaluating the subset of patients eligible for curative therapies, blacks and Hispanics had significantly lower rates of curative HCC treatment.
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Hepatitis C in African Americans. Am J Gastroenterol 2014; 109:1576-84; quiz 1575, 1585. [PMID: 25178700 DOI: 10.1038/ajg.2014.243] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 07/01/2014] [Indexed: 12/11/2022]
Abstract
The care of hepatitis C virus (HCV) in African Americans represents an opportunity to address a major health disparity in medicine. In all facets of HCV infection, African Americans are inexplicably affected, including in the prevalence of the virus, which is higher among them compared with most of the racial and ethnic groups. Ironically, although fibrosis rates may be slow, hepatocellular carcinoma and mortality rates appear to be higher among African Americans. Sustained viral response (SVR) rates have historically significantly trailed behind Caucasians. The reasons for this gap in SVR are related to both viral and host factors. Moreover, low enrollment rates in clinical trials hamper the study of the efficacy of anti-viral therapy. Nevertheless, the gap in SVR between African Americans and Caucasians may be narrowing with the use of direct-acting agents. Gastroenterologists, hepatologists, primary care physicians, and other health-care providers need to address modifiable risk factors that affect the natural history, as well as treatment outcomes, for HCV among African Americans. Efforts need to be made to improve awareness among health-care providers to address the differences in screening and referral patterns for African Americans.
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Abstract
BACKGROUND We sought to compare liver transplant waiting list access by demographics and geography relative to the pool of potential liver transplant candidates across the United States using a novel metric of access to care, termed a liver wait-listing ratio (LWR). METHODS We calculated LWRs from national liver transplant registration data and liver mortality data from the Scientific Registry of Transplant Recipients and the National Center for Healthcare Statistics from 1999 to 2006 to identify variation by diagnosis, demographics, geography, and era. RESULTS Among patients with ALF and CLF, African Americans had significantly lower access to the waiting list compared with whites (acute: 0.201 versus 0.280; pre-MELD 0.201 versus 0.290; MELD era: 0.201 versus 0.274; all, P<0.0001) (chronic: 0.084 versus 0.163; pre-MELD 0.085 versus 0.179; MELD 0.084 versus 0.154; all, P<0.0001). Hispanics and whites had similar LWR in both eras (both P>0.05). In the MELD era, female subjects had greater access to the waiting list compared with male subjects (acute: 0.428 versus 0.154; chronic: 0.158 versus 0.140; all, P<0.0001). LWRs varied by three-fold by state (pre-MELD acute: 0.122-0.418, chronic: 0.092-0.247; MELD acute: 0.121-0.428, chronic: 0.092-0.243). CONCLUSIONS The marked inequity in early access to liver transplantation underscores the need for local and national policy initiatives to affect this disparity.
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25
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Parsikia A, Ortiz J. Disparities in the reporting of distribution of health care. Liver Transpl 2014; 20:1149. [PMID: 24839271 DOI: 10.1002/lt.23913] [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: 05/06/2014] [Accepted: 05/06/2014] [Indexed: 01/12/2023]
Affiliation(s)
- Afshin Parsikia
- Department of Transplant Surgery, Einstein Healthcare Network, Einstein Medical Center, Philadelphia, PA
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Mataya L, Aronsohn A, Thistlethwaite R, Ross LF. Decision making in liver transplantation--limited application of the liver donor risk index. Liver Transpl 2014; 20:831-7. [PMID: 24692309 PMCID: PMC4072766 DOI: 10.1002/lt.23879] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/28/2014] [Indexed: 02/06/2023]
Abstract
The liver donor risk index (LDRI), originally developed in 2006 by Feng et al. and since modified, is a method of evaluating liver grafts from deceased donors through the determination of the relative risk of graft failure after transplantation. Online and paper surveys about attitudes and practices regarding decision making in liver transplantation and the role of the LDRI were sent to liver transplant physicians. One hundred forty-seven of 401 eligible respondents (37%) returned partial or complete surveys. The majority of the respondents were male (116/134 or 87%) and practiced in academic medical centers (128/138 or 93%). Transplant coordinators initially contacted the candidate with an offer in 81% of the programs. Eighty-eight of 143 respondents (62%) reported that they were very familiar with the LDRI, but the vast majority (114/137 or 83%) rarely or never discussed the concept of the LDRI with their patients. A majority of the respondents (96/132 or 73%) believed that the LDRI does not adequately describe a liver's relative risk of graft failure and that there are factors making the LDRI potentially misleading (122/138 or 88%). Nevertheless, 60 of 130 respondents (46%) believed that the LDRI would increase/improve shared decision making. The LDRI has not been widely adopted because of concerns that (1) it does not accurately reflect posttransplant survival, (2) it excludes relevant donor and recipient factors, and (3) it is too complicated for candidates to grasp. There is a need to improve it or to develop other decision-making tools to help promote shared decision making. There is also great diversity in how liver offers are made to ambulatory candidates and in how transplant programs address a candidate's refusal. Research is needed to determine evidence-based best practice.
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Affiliation(s)
- Leslie Mataya
- second year medical student at the University of Chicago Pritzker School of Medicine
| | | | | | - Lainie Friedman Ross
- Carolyn and Matthew Bucksbaum Professor of Clinical Medical Ethics, Professor in the Departments of Medicine, Pediatrics and Surgery; and Associate Director of the MacLean Center for Clinical Medical Ethics, University of Chicago
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Wong RJ, Ahmed A. Combination of racial/ethnic and etiology/disease-specific factors is associated with lower survival following liver transplantation in African Americans: an analysis from UNOS/OPTN database. Clin Transplant 2014; 28:755-61. [DOI: 10.1111/ctr.12374] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Robert J. Wong
- Division of Gastroenterology and Hepatology; Stanford University School of Medicine; Stanford CA USA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology; Stanford University School of Medicine; Stanford CA USA
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28
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Wong RJ, Devaki P, Nguyen L, Cheung R, Nguyen MH. Ethnic disparities and liver transplantation rates in hepatocellular carcinoma patients in the recent era: results from the Surveillance, Epidemiology, and End Results registry. Liver Transpl 2014; 20:528-35. [PMID: 24415542 DOI: 10.1002/lt.23820] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Accepted: 01/06/2014] [Indexed: 12/31/2022]
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality. After the implementation of the Model for End-Stage Liver Disease system, rates of liver transplantation (LT) for HCC patients increased. However, it is not clear whether this trend has continued into recent times. Using the Surveillance, Epidemiology, and End Results registry (1998-2010), we retrospectively analyzed trends for LT among HCC patients in 3 time periods: 1998-2003, 2004-2008, and 2009-2010. A total of 60,772 HCC patients were identified. In the more recent time periods, the proportion of localized-stage HCC increased (45.0% in 1998-2003, 50.4% in 2004-2008, and 51.7% in 2009-2010; P < 0.001). Although the proportion of HCC patients within the Milan criteria also increased with time (22.8% in 1998-2003, 31.8% in 2004-2008, and 37.1% in 2009-2010; P < 0.001), the proportion of those patients undergoing LT increased from 1998-2003 to 2004-2008 but decreased from 2004-2008 to 2009-2010. However, the actual frequencies of LT were similar in 2004-2008 (208.2 per year) and 2009-2010 (201.5 per year). A multivariate logistic regression, including sex, age, ethnicity, Milan criteria, tumor stage, tumor size and number, and time periods, demonstrated a lower likelihood of LT in 2009-2010 versus 1998-2003 [odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.57-0.71]. Blacks (OR = 0.48, 95% CI = 0.41-0.56), Asians (OR = 0.65, 95% CI = 0.57-0.73), and Hispanics (OR = 0.76, 95% CI = 0.68-0.85) were all less likely to undergo LT in comparison with non-Hispanic whites. Despite the increasing proportion of patients with HCC diagnosed at an earlier stage, LT rates declined in the most recent era. In addition, ethnic minorities were significantly less likely to undergo LT. The growing imbalance between the number of transplant-eligible HCC patients and the shortage of donor livers emphasizes the need to improve donor availability and curative alternatives to LT.
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Affiliation(s)
- Robert J Wong
- Liver Transplant Program, Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA; Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
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Czaja AJ. Autoimmune hepatitis in diverse ethnic populations and geographical regions. Expert Rev Gastroenterol Hepatol 2013; 7:365-85. [PMID: 23639095 DOI: 10.1586/egh.13.21] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Autoimmune hepatitis has diverse clinical phenotypes and outcomes in ethnic groups within a country and between countries, and these differences may reflect genetic predispositions, indigenous etiological agents, pharmacogenomic mechanisms and socioeconomic reasons. In the USA, African-American patients have cirrhosis more commonly, treatment failure more frequently and higher mortality than white American patients. Survival is poorest in Asian-American patients. Autoimmune hepatitis in other countries is frequently associated with genetic predispositions that may favor susceptibility to indigenous etiological agents. Cholestatic features influence treatment response; acute-on-chronic liver disease increases mortality and socioeconomic and cultural factors affect prognosis. Ethnic-based deviations from classical phenotypes and the frequency of late-stage disease can complicate the diagnosis and management of autoimmune hepatitis in non-white populations.
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Affiliation(s)
- Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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30
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Socioeconomic factors affect disparities in access to liver transplant for hepatocellular cancer. J Transplant 2012; 2012:870659. [PMID: 23304446 PMCID: PMC3529502 DOI: 10.1155/2012/870659] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 10/21/2012] [Accepted: 10/22/2012] [Indexed: 01/02/2023] Open
Abstract
Objective. The incidence/death rate of hepatocellular cancer (HCC) is increasing in America, and it is unclear if access to care contributes to this increase. Design/Patients. 575 HCC cases were reviewed for demographics, education, and tumor size. Main Outcome Measures. Endpoints to determine access to HCC care included whether an eligible patient underwent liver transplantation. Results. Transplant patients versus those not transplanted were younger (55.7 versus 61.8 yrs, P < 0.001), males (89.3% versus 74.4%, P = 0.013), and having completed high school (10.1% versus 1.2%, P = 0.016). There were differences in transplant by ethnicity, insurance, and occupation. Transplant patients with HCC had higher median income via census classification ($54,383 versus $49,383, P = 0.046) and self-reported income ($48,948 versus $38,800, P = 0.002). Differences in access may be related to exclusion criteria for liver transplant, as Pacific Islanders were more likely to have tumor size larger than 5 cm compared to Whites and have BMI > 35 (20.7%) compared to Whites (6.4%) and Asians (4.7%). Conclusions. Ethnic differences in access to transplant are associated with socioeconomic status and factors that can disqualify patients (advanced disease/morbid obesity). Efforts to overcome educational barriers and screening for HCC could improve access to transplant.
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Abstract
Because of the shortage of deceased donor organs, transplant centers accept organs from marginal deceased donors, including older donors. Organ-specific donor risk indices have been developed to predict graft survival with various combinations of donor and recipient characteristics. Here we review the kidney donor risk index (KDRI) and the liver donor risk index (LDRI) and compare and contrast their strengths, limitations, and potential uses. The KDRI has a potential role in developing new kidney allocation algorithms. The LDRI allows a greater appreciation of the importance of donor factors, particularly for hepatitis C virus-positive recipients; as the donor risk index increases, the rates of allograft and patient survival among these recipients decrease disproportionately. The use of livers with high donor risk indices is associated with increased hospital costs that are independent of recipient risk factors, and the transplantation of livers with high donor risk indices into patients with Model for End-Stage Liver Disease scores < 15 is associated with lower allograft survival; the use of the LDRI has limited this practice. Significant regional variations in donor quality, as measured by the LDRI, remain in the United States. We also review other potential indices for liver transplantation, including donor-recipient matching and the retransplant donor risk index. Although substantial progress has been made in developing donor risk indices to objectively assess donor variables that affect transplant outcomes, continued efforts are warranted to improve these indices to enhance organ allocation policies and optimize allograft survival.
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Affiliation(s)
| | | | - Yi Peng
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Peter Stock
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Ray Kim
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ajay K. Israni
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
- Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
- Department of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota
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Myers RP, Shaheen AAM, Aspinall AI, Quinn RR, Burak KW. Gender, renal function, and outcomes on the liver transplant waiting list: assessment of revised MELD including estimated glomerular filtration rate. J Hepatol 2011; 54:462-70. [PMID: 21109324 DOI: 10.1016/j.jhep.2010.07.015] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 07/02/2010] [Accepted: 07/05/2010] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS The Model for End-Stage Liver Disease (MELD) allocation system for liver transplantation (LT) may present a disadvantage for women by including serum creatinine, which is typically lower in females. Our objectives were to investigate gender disparities in outcomes among LT candidates and to assess a revised MELD, including estimated glomerular filtration rate (eGFR), for predicting waiting list mortality. METHODS Adults registered for LT between 2002 and 2007 were identified using the UNOS database. We compared components of MELD, MDRD-derived eGFR, and the 3-month probability of LT and death between genders. Discrimination of MELD, MELDNa, and revised models including eGFR for mortality were compared using c-statistics. RESULTS A total of 40,393 patients (36% female) met the inclusion criteria; 9% died and 24% underwent LT within 3 months of listing. Compared with men, women had lower median serum creatinine (0.9 vs. 1.0 mg/dl), eGFR (72 vs. 83 ml/min/1.73 m(2)), and mean MELD (16.5 vs. 17.2; all p <0.0005), but within most MELD strata, had higher bilirubin and INR. After adjusting for relevant covariates including creatinine and body weight, women were less likely than men to receive a LT (hazard ratio [HR] 0.85; 95% CI 0.79-0.87) and had greater 3-month mortality (HR 1.13; 95% CI 1.05-1.21). Revision of MELD and MELDNa to include eGFR did not improve discrimination for 3-month mortality (c-statistics: MELD 0.896, MELD-eGFR 0.894, MELDNa 0.911, MELDNa-eGFR 0.905). CONCLUSIONS Women are disadvantaged under MELD potentially due to its inclusion of creatinine. However, since including eGFR in MELD does not improve mortality prediction, alternative refinements are necessary.
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Affiliation(s)
- Robert P Myers
- Liver Unit, Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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33
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ASRANI SUMEETK, LIM YOUNGSUK, THERNEAU TERRYM, PEDERSEN RACHELA, HEIMBACH JULIE, KIM WRAY. Donor race does not predict graft failure after liver transplantation. Gastroenterology 2010; 138:2341-7. [PMID: 20176028 PMCID: PMC2907133 DOI: 10.1053/j.gastro.2010.02.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Revised: 01/26/2010] [Accepted: 02/09/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND & AIMS Donor race has been proposed to predict graft failure after liver transplantation. We evaluated the extent to which the center where the transplantation surgery was performed and other potential confounding factors might account for the observed association between donor race and graft failure. METHODS We analyzed data from the Organ Procurement and Transplantation Network (January 2003-December 2005) for adult patients undergoing primary liver transplantation in the United States. We examined the association between graft failure and the donor races of African American (AA), Caucasian, Asian/Pacific Islander (API), or those classified as other. RESULTS Of 10,874 livers that were donated for transplantation, 7631 came from Caucasians, 1579 from AAs, 243 from APIs, and 1421 from others. After 36 months of follow-up evaluation, 2687 grafts failed. Without any adjustments, AA donors (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.00-1.24), API donors (HR, 1.41; 95% CI, 1.12-1.77), and other donors (HR, 1.16; 95% CI, 1.04-1.29) were associated with graft failure. After stratification by center and adjustments for age, height, and hepatitis B core antibody status of donors as well as serum creatinine and hepatitis C status of recipients, donor race was no longer statistically significant for AA (HR, 1.06; 95% CI, 0.95-1.20) and API (HR, 1.15; 95% CI, 0.89-1.49) donors. However, livers donated from members of other race still had an increased risk of graft failure (HR, 1.19; 95% CI, 1.05-1.35), although the effect was not uniform across donor-recipient pairs. CONCLUSIONS Donor race is not a uniform predictor of graft failure and should not be construed as an indicator of donor quality.
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Affiliation(s)
- SUMEET K. ASRANI
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | | | - TERRY M. THERNEAU
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - RACHEL A. PEDERSEN
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - JULIE HEIMBACH
- William J. von Liebig Transplant Center, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - W. RAY KIM
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota,William J. von Liebig Transplant Center, Mayo Clinic College of Medicine, Rochester, Minnesota
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Yu JC, Neugut AI, Wang S, Jacobson JS, Ferrante L, Khungar V, Lim E, Hershman DL, Brown RS, Siegel AB. Racial and insurance disparities in the receipt of transplant among patients with hepatocellular carcinoma. Cancer 2010; 116:1801-9. [PMID: 20143441 DOI: 10.1002/cncr.24936] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND : Patients with hepatocellular carcinoma (HCC) have a poor prognosis if their tumors are not diagnosed early. The authors investigated factors associated with the receipt of liver transplant among patients with HCC and evaluated the effects of these differences on survival. METHODS : The authors reviewed records from consecutive patients diagnosed with HCC at Columbia University Medical Center from January 1, 2002 to September 1, 2008. We compared patient clinical and demographic characteristics, developed a multivariable logistic regression model of predictors of transplant, and used a Cox model to analyze predictors of mortality. RESULTS : Of 462 HCC patients, 175 (38%) received a transplant. Black patients were much less likely than whites to receive a transplant (odds ratio [OR], 0.03; 95% confidence interval [CI], 0.0-0.37). Hispanics and Asians were also less likely to undergo transplantation, but the differences were not statistically significant. Patients with private insurance were more likely to receive a transplant than those with Medicaid (odds ratio [OR], 22.07; 95% confidence interval [CI], 2.67-182.34). Black and Hispanic patients, and Medicaid recipients, presented with more advanced disease than whites and privately insured patients, and had poorer survival. In a Cox model, those who did not receive a transplant were 3 times as likely as transplant recipients to die, but race and insurance were not independently predictive of mortality. CONCLUSIONS : Race and insurance status were strongly associated with receipt of transplantation and with more advanced disease at diagnosis, but transplantation was the most important determinant of survival. Improved access to care for nonwhite and Medicaid patients may allow more patients to benefit from transplant. Cancer 2010. (c) 2010 American Cancer Society.
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Affiliation(s)
- Jeanette C Yu
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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Kemmer N, Neff GW. Liver transplantation in the ethnic minority population: challenges and prospects. Dig Dis Sci 2010; 55:883-9. [PMID: 19390965 DOI: 10.1007/s10620-009-0803-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2009] [Accepted: 03/17/2009] [Indexed: 01/20/2023]
Abstract
In the USA, end-stage liver disease (ESLD) is a major cause of morbidity and mortality among ethnic minorities. Ethnic populations vary with respect to chronic liver disease prevalence, access to transplantation, and therapeutic outcomes post liver transplantation. These ethnic differences present unique challenges to healthcare professionals involved in the care of patients with chronic liver disease prior and post transplantation. This review will discuss the variations and challenges of liver transplantation in the ethnic minority population.
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Affiliation(s)
- Nyingi Kemmer
- University of Cincinnati, MSB Room 6363, 231 Albert Sabin Way, Cincinnati, OH 45267-0595, USA.
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Burr AT, Shah SA. Disparities in organ allocation and access to liver transplantation in the USA. Expert Rev Gastroenterol Hepatol 2010; 4:133-40. [PMID: 20350260 DOI: 10.1586/egh.10.10] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Liver transplantation has become the standard of care for the treatment of chronic liver disease. In 1986, the United Network for Organ Sharing (UNOS) was formed to ensure the just and equitable allocation of donor livers. At the time, UNOS decided to use the Childs-Turcotte-Pugh scoring system to determine the degree of liver disease in potential transplant patients. Unfortunately, it was shown that the Childs-Turcotte-Pugh system was easily manipulated and did not provide equal access to donor organs. Owing to this fact, the Model of End Stage Liver Disease (MELD) score was instituted by UNOS in February 2002. While the institution of MELD has shown an improvement in organ allocation and outcomes, disparities still exist. This article discusses UNOS and the MELD allocation system as well as the racial, geographic and gender disparities that occur despite the institution of the MELD system.
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Affiliation(s)
- Andrew T Burr
- Solid Organ Transplantation, Department of Surgery, University of Massachusetts Medical School, Worcester, MA 01655, USA
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Fan PY, Ashby VB, Fuller DS, Boulware LE, Kao A, Norman SP, Randall HB, Young C, Kalbfleisch JD, Leichtman AB. Access and outcomes among minority transplant patients, 1999-2008, with a focus on determinants of kidney graft survival. Am J Transplant 2010; 10:1090-107. [PMID: 20420655 PMCID: PMC3644053 DOI: 10.1111/j.1600-6143.2009.03009.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Coincident with an increasing national interest in equitable health care, a number of studies have described disparities in access to solid organ transplantation for minority patients. In contrast, relatively little is known about differences in posttransplant outcomes between patients of specific racial and ethnic populations. In this paper, we review trends in access to solid organ transplantation and posttransplant outcomes by organ type, race and ethnicity. In addition, we present an analysis of categories of factors that contribute to the racial/ethnic variation seen in kidney transplant outcomes. Disparities in minority access to transplantation among wait-listed candidates are improving, but persist for those awaiting kidney, simultaneous kidney and pancreas and intestine transplantation. In general, graft and patient survival among recipients of solid organ transplants is highest for Asians and Hispanic/Latinos, intermediate for whites and lowest for African Americans. Although much of the difference in outcomes between racial/ethnic groups can be accounted for by adjusting for patient characteristics, important observed differences remain. Age and duration of pretransplant dialysis exposure emerge as the most important determinants of survival in an investigation of the relative impact of center-related versus patient-related variables on kidney graft outcomes.
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Affiliation(s)
- P.-Y. Fan
- Division of Renal Medicine, University of Massachusetts Medical School, Worcester, MA
| | - V. B. Ashby
- Scientific Registry of Transplant Recipients, University of Michigan, Ann Arbor, MI
| | - D. S. Fuller
- Scientific Registry of Transplant Recipients, Arbor Research Collaborative for Health, Ann Arbor, MI
| | - L. E. Boulware
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD,Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD
| | - A. Kao
- Department of Medicine, University of Missouri-Kansas City, St Luke's Mid America Heart Institute, Kansas City, MO
| | - S. P. Norman
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - H. B. Randall
- Department of Surgery, Baylor University Medical Center, Dallas, TX
| | - C. Young
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - J. D. Kalbfleisch
- Scientific Registry of Transplant Recipients, University of Michigan, Ann Arbor, MI
| | - A. B. Leichtman
- Scientific Registry of Transplant Recipients, University of Michigan, Ann Arbor, MI,Department of Internal Medicine, University of Michigan, Ann Arbor, MI,Corresponding author: Alan B. Leichtman,
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Artinyan A, Mailey B, Sanchez-Luege N, Khalili J, Sun CL, Bhatia S, Wagman LD, Nissen N, Colquhoun SD, Kim J. Race, ethnicity, and socioeconomic status influence the survival of patients with hepatocellular carcinoma in the United States. Cancer 2010; 116:1367-77. [PMID: 20101732 DOI: 10.1002/cncr.24817] [Citation(s) in RCA: 194] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Racial, ethnic, and socioeconomic disparities in the survival of patients with hepatocellular carcinoma (HCC) continue to exist. The authors of this report hypothesized that these differences result from inequities in access to care and in response to therapy. METHODS Patients with HCC (n = 20,920) were identified from the Surveillance, Epidemiology, and End Results (SEER) database, and patients who underwent liver transplantation for HCC (n = 4735) were identified from the United Network for Organ Sharing (UNOS) database. Clinical and pathologic factors were compared after patients were stratified by race and ethnicity. RESULTS The survival of patients with HCC improved over time for all racial, ethnic, and income groups (P < .001). Black and low income individuals had the poorest long-term survival (P < .001). On multivariate analysis, black race was predictive of the poorest survival (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.09-1.22; P < .001), whereas Asian race was associated with the best survival (HR, 0.87; 95% CI, 0.83-0.91; P < .001). After liver transplantation, black patients had the worst graft survival and overall survival (median survival [MS], 30.5 months and 39.7 months, respectively; P < .001), whereas Hispanics had the best survival (MS, 83.4 months and 86.6 months, respectively; P < .001). In a multivariate analysis of transplantation patients, race and ethnicity were associated significantly with outcome. CONCLUSIONS Significant racial and ethnic disparities in the outcome of patients with HCC persist despite the receipt of comparable treatment. The authors concluded that further investigations are warranted to identify the reasons for the stark disparity in outcomes between black patients and Hispanic patients after liver transplantation for HCC.
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Affiliation(s)
- Avo Artinyan
- Division of Oncologic Surgery, City of Hope, Duarte, CA, USA
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Mathur AK, Sonnenday CJ, Merion RM. Race and ethnicity in access to and outcomes of liver transplantation: a critical literature review. Am J Transplant 2009; 9:2662-8. [PMID: 20021478 PMCID: PMC3360978 DOI: 10.1111/j.1600-6143.2009.02857.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Racial/ethnic disparities in access to and outcomes of liver transplantation are an important topic given the increasing diversity in the United States. Most reports on this topic predate the advent of allocation based on the model for end-stage liver disease (MELD). For many patients with a variety of lethal conditions, liver transplantation is the only effective therapy, signifying the importance of equitable access to care. Racial/ethnic disparities have been described at various steps of the liver transplant process, including liver disease prevalence and treatment, access to a transplant center and its waitlist, receipt of a liver transplant and posttransplant outcomes. The purpose of this minireview is to critically evaluate the published literature on racial/ethnicity-based disparities in liver disease prevalence and treatment, transplant center referral, transplant rates and posttransplant outcomes. We identify the shortcomings of previous reports and detail the barriers to completing properly constructed analyses, particularly emphasizing deficits in requisite data and the need for improved study design. Understanding the nature of race/ethnicity-based disparities in liver transplantation is necessary to improve research initiatives, policy design and serves the broader responsibility of providing the highest quality care to all patients with liver disease.
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Affiliation(s)
- Amit K. Mathur
- Corresponding Author: Amit K. Mathur, MD, MS, University of Michigan Health System, 2207 Taubman Center, 1500 E Medical Center Drive, Ann Arbor, MI 48109-5342, Phone: (734) 936-5732, Fax: (734) 936-5725,
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40
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Forde KA, Reddy KR, Troxel AB, Sanders CM, Lee WM. Racial and ethnic differences in presentation, etiology, and outcomes of acute liver failure in the United States. Clin Gastroenterol Hepatol 2009; 7:1121-6. [PMID: 19501192 PMCID: PMC3642774 DOI: 10.1016/j.cgh.2009.05.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Accepted: 05/24/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In patients with chronic liver disease, race plays a role in the rate of survival after transplantation. It is not known how race and ethnicity influence the presentation, etiology, and outcomes in patients with acute liver failure (ALF). METHODS A retrospective cohort study was conducted using the ALF Study Group database to assess differences between racial and ethnic groups in subjects with ALF. RESULTS In the cohort of 927 subjects (81.8% white, 12.8% black, and 5.4% Asian), enrolled between January 1998 and March 2006, age, sex, and level of education were comparable among the groups. Differences were found in the prevalence of psychiatric illness and the use of medications. Racial groups also differed with respect to etiology of ALF. Whites presented more frequently with acetaminophen toxicity (51% vs 27%; P < .001). By day 21, 228 (30%) whites, 46 (39%) blacks, and 11 (22%) Asians had died. There were no significant differences found in the overall mortality rate after adjustment for potential confounders including etiology of ALF, encephalopathy, age, sex, admission laboratory values, and region. The odds of liver transplantation were higher among Asians and Hispanics; however, this finding was attenuated after adjustment for the previously-described confounders (adjusted odds ratio, 1.50; 95% confidence interval, 0.72-3.13; and adjusted odds ratio, 1.89; 95% confidence interval, 1.08-3.30, respectively). CONCLUSIONS In patients with ALF, there were no significant differences in survival or rate of liver transplantation among racial and ethnic groups except for transplantation in Hispanics.
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Affiliation(s)
- Kimberly A Forde
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, 3400 Spruce Street, 3 Ravdin, Philadelphia, Pennsylvania 19104, USA.
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Bzowej N, Han S, Degertekin B, Keeffe EB, Emre S, Brown R, Reddy R, Lok AS. Liver transplantation outcomes among Caucasians, Asian Americans, and African Americans with hepatitis B. Liver Transpl 2009; 15:1010-20. [PMID: 19718627 PMCID: PMC4438268 DOI: 10.1002/lt.21759] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Several previous studies found that Asians transplanted for hepatitis B virus (HBV) infection had worse post-transplant outcomes than Caucasians. Data on post-transplant outcomes of African Americans and waitlist outcomes of Asian Americans and African Americans with hepatitis B are scant. The aim of this study was to compare waitlist and post-transplant outcomes among Asian Americans, African Americans, and Caucasians who had HBV-related liver disease. Data from a retrospective-prospective study on liver transplantation for HBV infection were analyzed. A total of 274 patients (116 Caucasians, 135 Asians, and 23 African Americans) from 15 centers in the United States were enrolled. African Americans were younger and more Asian Americans had hepatocellular carcinoma (HCC) at the time of liver transplant listing. The probability of undergoing transplantation and the probability of survival on the waitlist were comparable in the 3 racial groups. Of the 170 patients transplanted, 19 died during a median follow-up of 31 months. The probability of post-transplant survival at 5 years was 94% for African Americans, 85% for Asian Americans, and 89% for Caucasians (P = 0.93). HCC recurrence was the only predictor of post-transplant survival, and recurrence rates were similar in the 3 racial groups. Caucasians had a higher rate of HBV recurrence: 4-year recurrence was 19% versus 7% and 6% for Asian Americans and African Americans, respectively (P = 0.043). In conclusion, we found similar waitlist and post-transplant outcomes among Caucasians, Asian Americans, and African Americans with hepatitis B. Our finding of a higher rate of HBV recurrence among Caucasians needs to be validated in other studies.
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Affiliation(s)
| | - Steven Han
- University of California, Los Angeles, CA
| | - Bulent Degertekin
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI
| | - Emmet B. Keeffe
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA
| | - Sukru Emre
- Mount Sinai Medical Center, New York, NY
| | - Robert Brown
- Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, New York, NY
| | | | - Anna S. Lok
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI
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Bryce CL, Angus DC, Arnold RM, Chang CCH, Farrell MH, Manzarbeitia C, Marino IR, Roberts MS. Sociodemographic differences in early access to liver transplantation services. Am J Transplant 2009; 9:2092-101. [PMID: 19645706 PMCID: PMC2880404 DOI: 10.1111/j.1600-6143.2009.02737.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The question of whether health care inequities occur before patients with end-stage liver disease (ESLD) are waitlisted for transplantation has not previously been assessed. To determine the impact of gender, race and insurance on access to transplantation, we linked Pennsylvania sources of data regarding adult patients discharged from nongovernmental hospitals from 1994 to 2001. We followed the patients through 2003 and linked information to records from five centers responsible for 95% of liver transplants in Pennsylvania during this period. Using multinomial logistic regressions, we estimated probabilities that patients would undergo transplant evaluation, transplant waitlisting and transplantation itself. Of the 144,507 patients in the study, 4361 (3.0%) underwent transplant evaluation. Of those evaluated, 3071 (70.4%) were waitlisted. Of those waitlisted, 1537 (50.0%) received a transplant. Overall, 57,020 (39.5%) died during the study period. Patients were less likely to undergo evaluation, waitlisting and transplantation if they were women, black and lacked commercial insurance (p < 0.001 each). Differences were more pronounced for early stages (evaluation and listing) than for the transplantation stage (in which national oversight and review occur). For early management and treatment decisions of patients with ESLD to be better understood, more comprehensive data concerning referral and listing practices are needed.
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Affiliation(s)
- C. L. Bryce
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,Section for Decision Sciences and Clinical Systems Modeling, University of Pittsburgh, Pittsburgh, PA,Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA,Corresponding author: Cindy L. Bryce,
| | - D. C. Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Laboratory, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA,Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - R. M. Arnold
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - C.-C. H. Chang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,Section for Decision Sciences and Clinical Systems Modeling, University of Pittsburgh, Pittsburgh, PA,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - M. H. Farrell
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - C. Manzarbeitia
- (former) Chair, Division of Transplant Surgery, Einstein Medical Center and Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - I. R. Marino
- Department of Surgery, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA
| | - M. S. Roberts
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,Section for Decision Sciences and Clinical Systems Modeling, University of Pittsburgh, Pittsburgh, PA,Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA,Department of Industrial Engineering, University of Pittsburgh, Pittsburgh, PA
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Kemmer N, Zacharias V, Kaiser TE, Neff GW. Access to liver transplantation in the MELD era: role of ethnicity and insurance. Dig Dis Sci 2009; 54:1794-7. [PMID: 19051029 DOI: 10.1007/s10620-008-0567-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 09/26/2008] [Indexed: 02/07/2023]
Abstract
Factors contributing to inequitable access to liver transplantation include socioeconomic status, geographic location, and delayed referral. The aim of this study is to identify the factors associated with a high MELD at the time of listing. Using the UNOS database, we identified all adults listed from 2002 to 2006. Data collected included demographics, insurance payor (private and government, i.e., Medicaid and non-Medicaid), diagnosis, and MELD score categorized as low (<20) and high (>or=20). The results obtained show that a high MELD was associated with age, ethnicity, and insurance (P < 0.001). By multivariate analysis, insurance (OR = 1.21, 95% CI = 1.13-1.30, P < 0.001) and ethnicity (OR = 1.55, 95% CI = 1.28-1.88, P < 0.001) were independently associated with high MELD. In conclusion, ethnic minorities and liver transplant candidates with Medicaid are more likely to have a high MELD score at initial listing. The above results suggest that the type of insurance and ethnicity are independently associated with a high MELD (i.e., sicker patients).
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Affiliation(s)
- Nyingi Kemmer
- University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0595, USA.
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44
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Carlé A, Laurberg P, Pedersen IB, Knudsen N, Perrild H, Ovesen L, Rasmussen LB, Jørgensen T. Mainly the younger hypothyroid patients are referred to hospital — Evidence for referral bias. J Clin Epidemiol 2009; 62:446-51. [DOI: 10.1016/j.jclinepi.2008.06.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Revised: 06/05/2008] [Accepted: 06/23/2008] [Indexed: 11/26/2022]
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Moylan CA, Brady CW, Johnson JL, Smith AD, Tuttle-Newhall JE, Muir AJ. Disparities in liver transplantation before and after introduction of the MELD score. JAMA 2008; 300:2371-8. [PMID: 19033587 PMCID: PMC3640479 DOI: 10.1001/jama.2008.720] [Citation(s) in RCA: 268] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
CONTEXT 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. DESIGN, SETTING, AND PATIENTS 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). MAIN OUTCOME MEASURES 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). CONCLUSION 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.
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Affiliation(s)
- Cynthia A Moylan
- Division of Gastroenterology, Duke University Medical Center, PO Box 3913, Durham, NC 27710, USA.
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46
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47
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Does Race Influence Outcomes after Primary Liver Transplantation? A 23-Year Experience with 2,700 Patients. J Am Coll Surg 2008; 206:1009-16; discussion 1016-8. [DOI: 10.1016/j.jamcollsurg.2007.12.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2007] [Accepted: 12/01/2007] [Indexed: 11/18/2022]
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Abstract
Liver transplantation is a life-saving therapy for patients with end-stage liver disease (ESLD); however, donor livers are scarce. Several studies have demonstrated racial disparities in access to liver transplant as well as patient and graft survival after liver transplantation. These studies used data gathered before the model for end-stage liver disease (MELD) was used to determine priority for liver transplant. In this issue of the journal, Drs. Ananthakrishnan and Saeian examine survival after transplant in the MELD era by race and ethnicity, and show that the racial disparities in posttransplant outcomes persist despite MELD. This study provides further evidence that race, which is likely a proxy for a variety of biological and sociological factors, must be considered in any prognostic model for liver transplantation. The impact of race on liver transplantation outcomes should be evaluated further in a well-designed, multicentered, prospective study.
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Abstract
Chronic liver diseases are a major public health issue in the United States, and there are substantial racial disparities in liver cirrhosis-related mortality. Hepatitis C virus (HCV) is the most significant contributing factor in the development of chronic liver disease, complications such as hepatocellular carcinoma, and the need for liver transplantation. In the United States, African Americans have twice the prevalence of HCV seropositivity and develop hepatocellular carcinoma at more than twice the rate as whites. African Americans are, however, less likely to respond to interferon therapy for HCV than are whites and have considerably lower likelihood of receiving liver transplantation, the only definitive therapy for end-stage liver disease. Even among those who undergo transplantation, African Americans have lower 2-year and 5-year graft and patient survival compared to whites. We will review these racial disparities in chronic liver diseases and discuss potential biological, socioeconomic, and cultural contributions. An understanding of their underlying mechanisms is an essential step in implementing measures to mollify racially based inequities in the burden and management of liver disease in an increasingly racially and ethnically diverse population.
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50
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Kemmer N, Safdar K, Kaiser T, Zacharias V, Neff GW. Impact of geographic location on access to liver transplantation among ethnic minorities. Transplantation 2008; 85:166-70. [PMID: 18212619 DOI: 10.1097/tp.0b013e31816223f8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Recent reports have documented ethnic disparity in access to health care. This disparity appears to exist in organ transplantation and the contributing factors include lack of insurance as well as poor socioeconomic status. The role of geographic location and ethnic composition on accessibility to liver transplantation (LT) is unclear. Therefore, the aim of this study was to determine ethnic transplantation trends based on United Network for Organ Sharing (UNOS) regions. METHODS Using the UNOS database, we identified all adults (> or =18 years) that received LT between 2000 and 2005. We excluded multiorgan transplants and living donor transplantation. The data collected included ethnicity, transplantation rate, and UNOS region. Data were analyzed using the chi test. RESULTS A total of 30,311 patients received a LT during the study period. Of these, 22,673 (74.8%) were white, 3621 (12%) were Hispanic, 2490 (8.2%) were African Americans, and the rest of other ethnic groups (5%). Liver transplantation based on ethnicity was region specific, with the lowest for African Americans in region 6 (2.7%), for Hispanics in region 11 (2.2%), and for whites in region 5 (57.6%), respectively. There was no consistent correlation between the ethnicity of the recipients and the ethnic composition of the geographic location (region). CONCLUSION Significant variations in access to liver transplantation for ethnic minorities exist across geographic lines. Understanding the interaction between ethnic minorities with end-stage liver disease in a geographic location and a transplant center will be invaluable as a first step in identifying the key nonmedical factors that play a role in this disparity.
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Affiliation(s)
- Nyingi Kemmer
- Division of Digestive Diseases, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45267-0595, USA.
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