After nine years of MELD, fundamental questions of fairness remain

Disparities in Liver Transplantation for Nonalcoholic Steatohepatitis in Women

BACKGROUND

Nonalcoholic steatohepatitis (NASH) is the fastest-growing indication for liver transplantation (LT). Sex disparities among patients with cirrhosis on the LT waitlist are well known. We wanted to understand these disparities further in women with end-stage liver disease patients listed for NASH cirrhosis in a contemporary cohort.

METHODS

We used data from the Scientific Registry of Transplant Recipients to assess sex racial, and ethnic differences in NASH patients listed for LT. Adults transplanted from August 1997 to June 2021 were included. Inferential statistics were used to evaluate differences with univariate and multivariate comparisons, including competitive risk analysis.

RESULTS

During the study time period, we evaluated 12 844 LT for NASH cirrhosis. Women were transplanted at a lower rate (46.5% versus 53.5%; P  < 0.001) and higher model for end-stage liver disease (MELD) (23.8 versus 22.6; P < 0.001) than men. Non-White women were transplanted at a higher MELD (26.1 versus 23.1; P  < 0.001) than White women and non-White male patients (26.1 versus 24.8; P  < 0.001). Graft and patient survivals were significantly different ( P  < 0.001) between non-White women and White women and men (White and non-White).

CONCLUSIONS

Evaluation of LT candidates in the United States demonstrates women with NASH cirrhosis have a higher MELD than men at LT. Additional disparities exist among non-White women with NASH as they have higher MELD and creatinine at LT compared with White women. After LT, non-White women have worse graft and patient survival compared with men or White women. These data indicate that non-White women with NASH are the most vulnerable on the LT waitlist.

Model for End-Stage Liver Disease: Is Sex-Based Creatinine Correction a Viable Strategy for Black Females?

BACKGROUND

The model for end-stage liver disease (MELD) is based on objective variables, including serum creatinine (SCr). This study assesses the influence of skin color on MELD scores calculated using SCr or corrected creatinine (CrC) in female candidates for liver transplantation (LTx).

METHODS

White and black women were eligible. The glomerular filtration rate (GFR) was calculated by means of the Modification of Diet in Renal Disease formula, using SCr. The GFR was then used for reverse calculation of CrC considering each female as male. The MELD scores were calculated using both creatinine values and compared between white and black candidates.

RESULTS

SCr-based and CrC-based scores were similar between groups. Calculated GFR was significantly higher in black women than in white women (P < 0.001). Use of CrC yielded 1-point, 2-point, and 3-point increases in the MELD score in 20.2%, 25.7%, and 17.5% of white patients, respectively. None of the black patients had a MELD score increase greater than 1 point. The CrC-based MELD calculation would benefit 63.4% of white females and only 26.1% of black females.

CONCLUSIONS

Use of CrC for MELD calculation would prioritize white females for liver allocation, but does not seem feasible, as it would not ensure equitable allocation across different ethnicities.