Factors influencing waiting time and successful receipt of cadaveric liver transplant in the United States. 1990 to 1992

The impact of waiting time and delayed treatment on the outcomes of patients with hepatocellular carcinoma: A systematic review and meta-analysis

Hepatocellular carcinoma (HCC) is the sixth most diagnosed cancer worldwide. Healthcare resource constraints may predispose treatment delays. We aim to review existing literature on whether delayed treatment results in worse outcomes in HCC. PubMed, Embase, The Cochrane Library, and Scopus were systematically searched from inception till December 2022. Primary outcomes were overall survival (OS) and disease-free survival (DFS). Secondary outcomes included post-treatment mortality, readmission rates, and complications. Fourteen studies with a total of 135,389 patients (delayed n = 25,516, no delay n = 109,873) were included. Age, incidence of male patients, Child-Pugh B cirrhosis, and Barcelona Clinic Liver Cancer Stage 0/A HCC were comparable between delayed and no delay groups. Tumor size was significantly smaller in delayed versus no delay group (mean difference, -0.70 cm; 95% confidence interval [CI]: -1.14, 0.26; p = 0.002). More patients received radiofrequency ablation in delayed versus no delay group (OR, 1.22; 95% CI: 1.16, 1.27; p < 0.0001). OS was comparable between delayed and no delay in HCC treatment (hazard ratio [HR], 1.13; 95% CI: 0.99, 1.29; p = 0.07). Comparable DFS between delayed and no delay groups (HR, 0.99; 95% CI: 0.75, 1.30; p = 0.95) was observed. Subgroup analysis of studies that defined treatment delay as > 90 days showed comparable OS in the delayed group (HR, 1.04; 95% CI: 0.93, 1.16; p = 0.51). OS and DFS for delayed treatment were non-inferior compared to no delay, but might be due to better tumor biology/smaller tumor size in the delayed group.

Liver Transplant Recipients' First Year of Posttransplant Recovery: A Longitudinal Study

A longitudinal study of 20 liver transplant recipients was conducted to investigate their posttransplant recovery experience. Data were collected using semistructured interviews at 6 weeks, 6 months, and 1 year after transplantation. Qualitative analysis of data revealed physical, psychological, social, economic, and spiritual dimensions of recovery. Findings reflect ongoing improvement of physical health and functionality for most recipients. Those with continuing health problems often suffered from preexisting health conditions. Psychological adjustment was uneven, with intermittent periods of fear, anxiety, and depression. Some recipients reported short-lived split identities and personality changes. Social support of family was critical in the hospital and at home. Economic issues became primary by the 1-year interview, with all recipients questioning whether they could afford ongoing healthcare and medicines. Spiritual needs were met in secular and nonsecular activities. Findings suggest that healthcare personnel should attend to the lived experience of liver transplant recipients.

Influence of age and gender before and after liver transplantation

Women constitute a particular group among patients with chronic liver disease and in the post-liver transplantation (LT) setting: they are set apart not only by traditional differences with respect to men (ie, body mass index, different etiologies of liver disease, and accessibility to transplantation) but also in increasingly evident ways related to hormonal changes that characterize first the fertile age and subsequently the postmenopausal period (eg, disease course variability and responses to therapy). The aim of this review is, therefore, to evaluate the role of the interplay of factors such as age, gender, and hormones in influencing the natural history of chronic liver disease before and after LT and their importance in determining outcomes after LT. As the population requiring LT ages and the mean age at transplantation increases, older females are being considered for transplantation. Older patients are at greater risk for nonalcoholic steatohepatitis, osteoporosis, and a worse response to antiviral therapy. Female gender per se is associated with a greater risk for osteoporosis because of metabolic changes after menopause, the bodily structure of females, and, in the population of patients with chronic liver disease, the greater prevalence of cholestatic and autoimmune liver diseases. With menopause, the fall of protective estrogen levels can lead to increased fibrosis progression, and this represents a negative turning point for women with chronic liver disease and especially for patients with hepatitis C. Therefore, the notion of gender as a binary female/male factor is now giving way to the awareness of more complex disease processes within the female gender that follow hormonal, social, and age patterns and need to be addressed directly and specifically.

Geographic variation in organ availability is responsible for disparities in liver transplantation between Hispanics and Caucasians

The aims of this study were to determine whether disparities in waiting list outcomes exist for Hispanics and African Americans during the post-MELD era, and to investigate interactions between disparities and geography. Scientific Registry of Transplant Recipients data were used to compare Hispanics and African Americans to Caucasians listed between 2003 and 2008. Endpoints included (i) receipt of a liver transplant and (ii) death or removal from the waiting list for being too sick or medically unsuitable. Adjustment for possible confounders was performed using multivariate Cox regression, with adjustment for geographic variation using a fixed-effects multilevel model. In multivariate analysis, African Americans have similar hazard of transplantation and death/removal as Caucasians during the post-MELD era. However, Hispanics are less likely to receive a transplant than Caucasians despite adjustment for potential confounders (HR 0.80, 95% CI 0.77-0.83), while having a similar hazard of death/removal. This effect disappeared after adjusting for unequal regional distribution of Hispanics, who represent 8% of patients in donation service areas (DSAs) having median waiting times of < or = 155 days versus 19% in DSAs with median waiting times of >155 days. In conclusion, disparities in liver transplantation exist for Hispanics during the post-MELD era, caused by geographic variation in organ availability.

Age and comorbidities are effect modifiers of gender disparities in renal transplantation

Women have less access to kidney transplantation than men, but the contributions of age and comorbidity to this disparity are largely unknown. We conducted a national cohort study of 563,197 patients with first-onset ESRD between 2000 and 2005. We used multivariate generalized linear models to evaluate both access to transplantation (ATT), defined as either registration for the deceased-donor waiting list or receiving a live-donor transplant, and survival benefit from transplantation, defined as the relative rate of survival after transplantation compared with the rate of survival on dialysis. We compared relative risks (RRs) between women and men, stratified by age categories and the presence of common comorbidities. Overall, women had 11% less ATT than men. When the model was stratified by age, 18- to 45-yr-old women had equivalent ATT to men (RR 1.01), but with increasing age, ATT for women declined dramatically, reaching a RR of 0.41 for those who were older than 75 yr, despite equivalent survival benefits from transplantation between men and women in all age subgroups. Furthermore, ATT for women with comorbidities was lower than that for men with the same comorbidities, again despite similar survival benefits from transplantation. This study suggests that there is no disparity in ATT for women in general but rather a marked disparity in ATT for older women and women with comorbidities. These disparities exist despite similar survival benefits from transplantation for men and women regardless of age or comorbidities.

Neighborhood poverty and kidney transplantation among US Asians and Pacific Islanders with end-stage renal disease

The degree to which low transplant rates among Asians and Pacific Islanders in the United States are confounded by poverty and reduced access to care is unknown. We examined the relationship between neighborhood poverty and kidney transplant rates among 22 152 patients initiating dialysis during 1995-2003 within 1800 ZIP codes in California, Hawaii and the US-Pacific Islands. Asians and whites on dialysis were distributed across the spectrum of poverty, while Pacific Islanders were clustered in the poorest areas. Overall, worsening neighborhood poverty was associated with lower relative rates of transplant (adjusted HR [95% CI] for areas with > or =20% vs. <5% residents living in poverty, 0.41 [0.32-0.53], p < 0.001). At every level of poverty, Asians and Pacific Islanders experienced lower transplant rates compared with whites. The degree of disparity increased with worsening neighborhood poverty (adjusted HR [95% CI] for Asians-Pacific Islanders vs. whites, 0.64 [0.51-0.80], p < 0.001 for areas with <5% and 0.30 [0.21-0.44], p < 0.001 for areas with > or =20% residents living in poverty; race-poverty level interaction, p = 0.039). High levels of neighborhood poverty are associated with lower transplant rates among Asians and Pacific Islanders compared with whites. Our findings call for studies to identify cultural and local barriers to transplant among Asians and Pacific Islanders, particularly those residing in resource-poor neighborhoods.

Racial differences in liver transplantation outcomes in the MELD era

OBJECTIVES

Beginning February 28, 2002, the Model for End-Stage Liver Disease (MELD) score was introduced to better allocate donor livers. Racial differences in orthotopic liver transplantation (OLT) outcomes prior to this time have been attributed to late listing of some racial groups. Racial differences in post-transplant survival in the MELD era have not been previously examined.

METHODS

We performed a retrospective observational cohort study using the United Network for Organ Sharing database for adult liver transplants performed between 2002 and 2006. We examined patient and graft survival at 2 yr and compared disease-specific survival rates among the different races.

RESULTS

A total of 10,409 whites, 1,133 blacks, 1,548 Hispanics, and 765 transplant recipients belonging to other races were included in the study. On multivariate analysis, blacks had lower overall (hazard ratio for death [HR] 1.29, 95% confidence interval [95% CI] 1.10-1.52) and graft (HR 1.38, 95% CI 1.20-1.58) survival at 2 yr compared to whites, while Hispanics had better overall (HR 0.78) and graft (HR 0.82) survival. Compared to whites, blacks transplanted for hepatitis C or HCC had lower survival at 2 yr.

CONCLUSION

In the MELD era, black patients have significantly lower overall and graft survival at 2 yr compared to whites.

A healthy mistrust: how worldview relates to attitudes about breast cancer screening in a cross-sectional survey of low-income women

BACKGROUND

Perceived racial discrimination is one factor which may discourage ethnic minorities from using healthcare. However, existing research only partially explains why some persons do accept health promotion messages and use preventive care, while others do not. This analysis explores 1) the psychosocial characteristics of those, within disadvantaged groups, who identify their previous experiences as racially discriminatory, 2) the extent to which perceived racism is associated with broader perspectives on societal racism and powerlessness, and 3) how these views relate to disadvantaged groups' expectation of mistreatment in healthcare, feelings of mistrust, and motivation to use care.

METHODS

Using survey data from 576 African-American women, we explored the prevalence and predictors of beliefs and experiences related to social disengagement, racial discrimination, desired and actual racial concordance with medical providers, and fear of medical research. We then used both sociodemographic characteristics, and experiences and attitudes about disadvantage, to model respondents' scores on an index of personal motivation to receive breast cancer screening, measuring screening knowledge, rejection of fatalistic explanatory models of cancer, and belief in early detection, and in collaborative models of patient-provider responsibility.

RESULTS

Age was associated with lower motivation to screen, as were depressive symptoms, anomie, and fear of medical research. Motivation was low among those more comfortable with African-American providers, regardless of current provider race. However, greater awareness of societal racism positively predicted motivation, as did talking to others when experiencing discrimination. Talking was most useful for women with depressive symptoms.

CONCLUSION

Supporting the Durkheimian concepts of both anomic and altruistic suicide, both disengagement (depression, anomie, vulnerability to victimization, and discomfort with non-Black physicians) as well as over-acceptance (low awareness of discrimination in society) predict poor health maintenance attitudes in disadvantaged women. Women who recognize their connection to other African-American women, and who talk about negative experiences, appear most motivated to protect their health.

Racial disparities in utilization of liver transplantation for hepatocellular carcinoma in the United States, 1998-2002

BACKGROUND AND AIMS

The extent of use of liver transplantation on a population scale to treat hepatocellular carcinoma (HCC) in the United States is unknown. We assessed recent predictors of use of liver transplantation and its effect on survival for those with nonmetastatic HCC.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) program is a collection of population-based cancer registries. We identified adults registered in SEER with HCC between 1998 and 2002. We examined determinants for receipt of a liver transplant in univariate and multivariable analyses. Kaplan-Meier survival curves were constructed for those who received and did not receive a transplant for HCC.

RESULTS

We identified 1,156 adults with small (5 cm or less) nonmetastatic HCC. Approximately 45% were white, 29% Asian, 17% Hispanic, and 9% African American. Only 21% received a transplant. More recent year of diagnosis, younger age, being married, white race, and smaller tumor size each predicted receipt of transplant. African Americans and Asians were about half as likely to receive a transplant as compared with white patients (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.21-0.90 for African Americans, and 0.57, 95% CI 0.36-0.89 for Asians). Hispanics trended in the same direction, but this was not statistically significant (OR 0.66, 95% CI 0.39-1.12). Those who underwent liver transplantation for localized HCC had 3- and 5-yr survivals of 81% and 75%, respectively.

CONCLUSIONS

Only one-fifth of those with small, nonmetastatic HCC received liver transplantation. Transplanted patients have long-term survival similar to that of the best single-institution studies. However, marked racial variations were seen, with African Americans and Asians significantly less likely to receive a transplant after controlling for other variables.

Racial disparities in the management of hospitalized patients with cirrhosis and complications of portal hypertension: a national study

Having complications of portal hypertension is a harbinger of decompensated cirrhosis and warrants consideration for liver transplantation (LT). Racial disparities in LT have been reported. We sought to characterize disparities in the performing of surgical and endoscopic procedures among hospitalized patients with complications of portal hypertension. We queried the Nationwide Inpatient Sample from 1998 to 2003 to identify patients with cirrhosis and complications of portal hypertension. Logistic regression controlling for confounders was used to evaluate race as a predictor of undergoing a portosystemic shunt and LT and of dying in the hospital. Compared to whites, the adjusted odds ratios of receiving a portosystemic shunt were 0.37 (95% CI: 0.27-0.51) and 0.69 (95% CI: 0.54-0.88) for African Americans (AAs) and Hispanics, respectively. AAs with variceal bleeding were more likely to have endoscopic variceal hemostasis delayed more than 24 hours after admission than were whites (OR 1.6; 95% CI: 1.2-2.1). The adjusted odds ratios of undergoing LT were 0.32 (95% CI:0.20-0.52) and 0.46 (95% CI: 0.25-0.83) for AAs and Hispanics, respectively. Compared to whites, AAs experienced higher in-hospital mortality (OR 1.12; 95% CI: 1.01-1.24), whereas Hispanics had a lower risk of death (OR 0.83; 95% CI: 0.75-0.92). Among variceal bleeders, the odds ratio of death for AAs was 1.7 (95% CI: 1.2-2.4) compared to whites.

CONCLUSION

AAs and Hispanics hospitalized for complications of portal hypertension were less likely to undergo a palliative shunt or LT than whites, which may contribute to the higher in-hospital mortality of AAs. Further studies are warranted to elucidate the mechanisms of these exploratory findings.

Public and private regulation of organ transplantation: liver allocation and the final rule

The allocation of cadaveric organs for transplantation in the United States is governed by a process of private regulation. Through the Organ Procurement and Transplantation Network (OPTN), stakeholders and public representatives determine the substantive content of allocation rules. Between 1994 and 2000 the U.S. Department of Health and Human Services conducted a rule making to define more clearly the public and private roles in the determination of organ allocation policy. Several prominent liver transplant centers that were losing market share as a result of the proliferation of transplant centers used the rule making as a vehicle for challenging the local priority for organ allocation inherent in the OPTN rules. The process leading to the final rule provides a window on the politics of organ allocation. It also facilitates an assessment of the strengths and weaknesses of private rule making. Overall, private rule making appears to be relatively effective in tapping the technical expertise and tacit knowledge of stakeholders to allow for the adaptation of rules in the face of changing technology and information. However, the particular system of representation employed may give less influence to some stakeholders than they would have in public regulatory arenas, giving them an incentive to seek public rule making as a remedy for their persistent losses within the framework of private rule making.

Risk factors for liver transplantation waiting list mortality

BACKGROUND AND AIM

The gap between the demand for liver transplantation and organ donation rates has a major impact on waiting list mortality. Understanding the risk factors that predict liver transplant waiting list death may help optimize organ allocation policy and reduce waiting list deaths.

METHODS

We analyzed risk factors associated with waiting list mortality in the Liver Transplant Unit Victoria for the period 1988 through 2004.

RESULTS

The mean annual waiting list mortality for the period examined was 10.2% (10.6% for adult and 6.4% for pediatric patients). Factors associated with waiting list death included female sex, fulminant hepatic failure, primary non-function, blood group O, more urgent United Network for Organ Sharing (UNOS)-derived medical status, a Child-Turcotte-Pugh (CTP) score >or=11, a model for end-stage liver disease (MELD) score >or=20, and a pediatric end-stage liver disease score >or=20. UNOS-derived medical status, CTP class, and MELD score were significant at the multivariate level.

CONCLUSIONS

Disease severity scores, such as MELD, predict the risk of liver transplantation waiting list mortality. Use of such scores in organ allocation in Australian liver transplant units may result in reduced waiting list mortality.

Differential mortality and transplantation rates among Asians and Pacific Islanders with ESRD

Few studies in patients with ESRD have examined outcomes in Asian or Pacific Islander subgroups compared with white individuals. The objective of this study was to assess ethnic disparities in mortality and kidney transplantation among a multiethnic cohort of incident dialysis patients. A total of 24,963 patients who initiated dialysis within the TransPacific Renal Network (Network 17) between April 1, 1995, and September 30, 2001, were studied to ascertain death and kidney transplantation through September 30, 2002. Overall, 12,902 deaths and 2258 kidney transplantations were observed during 59,075 person-years of follow-up. Mortality on dialysis among Asians and Pacific Islanders (except Chamorros) was lower than that of white individuals after controlling for differences in sociodemographic characteristics, comorbid conditions, and other risk factors for death (adjusted hazard ratio [95% confidence interval] versus white individuals: Japanese 0.64 [0.57 to 0.72], Chinese 0.64 [0.52 to 0.78], Filipino 0.64 [0.57 to 0.72], Native Hawaiian 0.84 [0.72 to 0.96], Samoan 0.62 [0.48 to 0.82], and Chamorro 0.96 [0.84 to 1.20]). In contrast, Asians and Pacific Islanders were much less likely to undergo kidney transplantation (adjusted rate ratio [95% confidence interval] versus white individuals: Japanese 0.34 [0.24 to 0.46], Chinese 0.54 [0.30 to 0.88], Filipino 0.32 [0.26 to 0.47], Native Hawaiian 0.17 [0.10 to 0.30], Samoan 0.17 [0.07 to 0.38], and Chamorro 0.04 [0.01 to 0.14]). Despite wide variations in primary cause of ESRD, clinical characteristics, and body size at dialysis initiation, Asians and Pacific Islanders experience better survival but substantially lower transplantation rates compared with white individuals. Strategies that are aimed at improving access to transplantation in Asian and Pacific Islander communities may further enhance survival among Asians and Pacific Islanders with ESRD.

Ability to pay and geographical proximity influence access to liver transplantation even in a system with universal access

Ireland, in common with many countries, has a mixed private and public health care system. Concern has been expressed that this system may lead to inequity in access to medical treatment. To investigate this concern, all contacts and first admissions to the national liver transplant unit were identified between April 1, 2000, and March 31, 2002. The effects of private health insurance and area of residence on the likelihood of receiving a liver transplant were assessed. A total of 202 patients were admitted. Forty-three patients from this cohort received a liver transplant (21.3%). Of patients with private health insurance, 17 of 50 (34.0%) were transplanted, compared with 26 of 152 (17.1%) without private health insurance (relative risk [RR] = 1.99; 95% CI, 1.18-3.35; P = .01). For residents of the Eastern (close to the liver transplant unit), patients with private health insurance were no more likely to be transplanted (RR = 0.95; 95% CI, 0.35-2.54; P = 1.0), whereas for residents of other areas, patients with private insurance were 3 times more likely to receive a transplant than those without health insurance (RR = 3.11; 95% CI, 1.59-6.08; P = .001). Patients living outside the Eastern region without private health insurance were only half as likely as all other patient types combined to receive a transplant (RR = 0.52; 95% CI, 0.29-0.92; P = .02). In this study the possession of private health insurance appeared to increase the chances of receiving a liver transplant. Patients without private health insurance living distant from the liver transplant unit appeared particularly disadvantaged. In conclusion, these findings suggest significant inequity in liver transplant allocation in Ireland and deserve further assessment.

Disparity in use of orthotopic liver transplantation among blacks and whites

Orthotopic liver transplantation (OLT) is the best treatment for end-stage liver disease. Limited data exist on the access of minorities to OLT. The aim of this study was to determine whether disparities exist among black and white OLT patients. Data were collected from the United Network for Organ Sharing on black and white 18-70 year-old OLT waiting list registrants (n = 29,013) and OLT recipients (n = 15,805) between 1994 and 1998. Standardized transplant ratios were generated by comparing the racial distribution of OLT patients with the US population. Demographic and clinical characteristics of OLT registrants were compared by race. Multivariate analyses were performed to identify predictors of time to OLT and the likelihood of dying or receiving OLT within 4 years, controlling for severity of illness and other factors. The standardized transplant ratio for black OLT recipients (0.65) was significantly lower than the standardized transplant ratio for white OLT recipients (1.05). Blacks were younger and sicker than whites. After adjustment for severity and other factors, time to OLT among recipients did not differ by race (P >.05). Blacks were more likely to die or become too ill for OLT while waiting (P <.001). Blacks were less likely to receive OLT within 4 years (P <.001). In conclusion, adult blacks were underrepresented among OLT patients. Although waiting times were similar once listed, black race affected outcomes while awaiting OLT. The process of referral and evaluation for OLT should be investigated further.

Impact of adult living donor liver transplantation on waiting time survival in candidates listed for liver transplantation

Studies comparing adult living donor liver transplantation to deceased donor liver transplantation have focused on post-transplant survival. Our aim was to focus on the impact of living donor liver transplant on waiting time mortality and overall mortality. We analyzed the affect of living donor liver transplantation on waiting time mortality and overall mortality (from listing until last follow up) in a cohort of 116 transplant candidates. Fifty-eight candidates who had individuals present as potential living donors (volunteer group) were matched by MELD score to 58 liver transplant candidates who did not have individuals present as a potential living donor (no volunteer group). Twenty-seven percent of candidates in the no volunteer group and 62% of candidates in the volunteer group underwent liver transplantation, p = 0.0003. One-year waiting list mortality for the volunteer group and no volunteer group was 10% and 20%, respectively, p = 0.03. Patient survival from the time of listing to last follow up was similar between the two groups. In our study group, living donor liver transplantation is associated with a higher rate of liver transplantation and lower waiting time mortality. In the era of living donor liver transplantation, estimates of patient survival should incorporate waiting time mortality.

Geographic disparities in access to organ transplant in France

BACKGROUND

Allocation of organs is organized on a regional basis in France. We assessed regional differences in access to organ transplant.

MATERIAL AND METHODS

We used the recipient database and the waiting list database from the year 1994 onward. We estimated median waiting time by region and organ. The probability of receiving a transplant was estimated using the Kaplan-Meier method. Between-region comparisons used the log-rank test, with adjustment for blood type and disease category.

RESULTS

At the end of a 4-month follow-up period, 49% of 3,553 patients had received transplants: 64% of 797 benefited from liver transplants, 52% of 549 from heart transplants, and 22% of 2,207 from kidney transplants. Death rates on the waiting lists were 10%, 14%, and 1% for patients selected for liver, heart, and kidney transplant, respectively. Transplantation percentage (all organs) decreased from 63% in the West to 43% in the Paris region and mortality increased from 2% in the West to 7% in the Southeast. All tests of inter-regional differences were statistically significant.

CONCLUSION

Factors explaining geographic differences related to the background of transplant teams, activity of organ procurement, and severity of patients on the list.

Lung allocation in the United States, 1995-1997: an analysis of equity and utility

BACKGROUND

Waiting time for organ transplantation varies widely between programs of different sizes and by geographic regions. The purpose of this study was to determine if the current lung-allocation policy is equitable for candidates waiting at various-sized centers, and to model how national allocation based solely on waiting time might affect patients and programs.

METHODS

UNOS provided data on candidate registrations; transplants and outcomes; waiting times; and deaths while waiting for all U.S. lung-transplant programs during 1995-1997. Transplant centers were categorized based on average yearly volume: small (< or = 10 pounds sterling transplants/year; n = 46), medium (11-30 transplants/year; n = 29), or large (>30 transplants/year; n = 6). This data was used to model national organ allocation based solely on accumulated waiting time for candidates listed at the end of 1997.

RESULTS

Median waiting time for patients transplanted was longest at large programs (724-848 days) compared to small and medium centers (371-552 days and 337-553 days, respectively) and increased at programs of all sizes during the study period. Wait-time-adjusted risk of death correlated inversely with program size (365 vs 261 vs 148 deaths per 1,000 patient-years-at-risk at small, medium, and large centers, respectively). Mortality as a percentage of new candidate registrations was similar for all program categories, ranging from 21 to 25%. Survival rates following transplantation were equivalent at medium-sized centers vs large centers (p = 0.50), but statistically lower when small centers were compared to either large- or medium-size centers (p < or = 0.05). Using waiting time as the primary criterion lung allocation would acutely shift 10 to 20% of lung-transplant activity from medium to large programs.

CONCLUSIONS

1) Waiting list mortality rates are not higher at large lung-transplant programs with long average waiting times. 2) A lung-allocation algorithm based primarily on waiting-list seniority would probably disadvantage candidates at medium-size centers without improving overall lung-transplant outcomes. 3) If fairness is measured by equal distribution of opportunity and risk, we conclude that the current allocation system is relatively equitable for patients currently entering the lung-transplant system.

Analysis of the French liver transplant waiting list, 1992-1996

BACKGROUND

In organ transplantation, each country has specific rules of allocation. We have retrospectively evaluated the French liver transplant waiting list for the period 1992-1996, during which time the rules for allocation remained stable. Mortality while on the waiting list and waiting times were the two principal endpoints.

METHODS

Using the Etablissement Français des Greffes (EFG) registry, the study was conducted in three steps: (1) description of the waiting list population; (2) analysis of the outcome of patients, with the use of a logistic model to explain death while on the waiting list; (3) estimation of waiting times and use of a Cox model to explain waiting times.

RESULTS

The distribution of patients with regard to degree of urgency, age, blood type, and liver disease was variable according to the the EFG region. The outcome of patients was variable according to blood type and to EFG region. Patients classed as "extremely urgent" did not have a different outcome compared to elective patients. The logistic model indicated that two factors influenced the death: blood group and EFG region. Waiting times were variable according to EFG region; age and blood group had an influence on waiting times for a graft. The Cox model indicated the independent influence of EFG region on waiting times.

CONCLUSION

We found geographical disparities between patients with respect to time on the waiting list. However, the database must be improved by including the risk profile of each patient, leading to changes in rules for a better allocation of transplants.