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Liver Transplant Allocation

Transplantation is the only treatment for end-stage liver failure, but suitable donor organs are in short supply. A new allocation scheme implemented in 2002 has improved racial disparities among transplant recipients, but women are still at a disadvantage, according to an analysis published in the November 26, 2008 Journal of the American Medical Association. C. Moylan and colleagues assessed the association between race, sex, and liver transplantation following introduction of the Model for End-Stage Liver Disease (MELD) system in February 2002. MELD estimates the risk of death within three months based on bilirubin and creatinine levels and prothrombin time. The researchers looked at a retrospective cohort of 21,895 adult patients on the United Network for Organ Sharing (UNOS) liver transplant waiting list between January 1996 and December 2000 (pre-MELD) and 23,793 patients added to the list between February 2002 and March 2006 (post-MELD).

Overall, black patients were younger and sicker than white patients on the waiting list during both periods. In the pre-MELD cohort, black patients were significantly more likely than whites to die or become too sick for transplantation within three years of registering on the waiting list (27.0% vs. 21.7%; odds ratio [OR] 1.51); blacks were also less likely than whites to receive a liver transplant during this period (61.6% vs. 66.9%; OR 0.75). By contrast, in the post-MELD cohort, black race was no longer associated with increased likelihood of death or becoming too sick for transplantation (26.5% vs. 22.0%; OR 0.96), and blacks were no less likely than whites to receive a transplant (47.5% vs. 45.5%; OR 1.04).

However, unlike the pre-MELD cohort, women were significantly more likely than men to die or become too sick for transplantation in the post-MELD period (23.7% vs. 21.4%; OR 1.30). Women were less likely than men to receive transplants within three years during both the pre-MELD (64.8% vs. 67.6%; OR 0.80) and post-MELD (39.9% vs. 48.7%; OR 0.70) periods. Following introduction of the MELD score, the researchers concluded, "race was no longer associated with receipt of a liver transplant or death on the waiting list, but disparities based on sex remain." They added that the elimination of the racial disparity likely reflects the fact that the MELD score accounts for the severity of disease when a patient is put on the waiting list. Women may receive fewer transplants due to their smaller size, since small donor livers may be used for large patients, but not vice versa.