Disparities in Liver Transplant Allocation Shift but Still Exist

[Guest guest]

http://www.medpagetoday.com/Gastroenterology/LiverTransplantation/11918

Disparities in Liver Transplant Allocation Shift but Still Exist

By Gever, Senior Editor, MedPage Today

Published: November 25, 2008

Reviewed by Zalman S. Agus, MD; Emeritus Professor

University of Pennsylvania School of Medicine.

Video source: JAMA

DURHAM, N.C., Nov. 25 -- The objective scoring system adopted in 2002 for

allocating livers for transplantation has put women at a disadvantage, even as

it appears to have eliminated an earlier racial disparity, researchers here

said.

Black patients eligible for liver transplants are no longer more likely than

whites to die or become too ill for the procedure while awaiting a suitable

donor, reported A. Moylan, M.D., of Duke University, and colleagues in

the Nov. 26 issue of the Journal of the American Medical Association.

But after adoption of the MELD (Model for End-Stage Liver Disease) scoring

system in 2002, women became 30% more likely than men to die or become too ill

for transplant (95% CI 8% to 47%). Action Points

--------------------------------------------------------------------------------

Explain to interested patients that the study found that black patients with

end-stage liver disease were no more likely than white patients to die or become

too sick for transplant while waiting for a donor liver.

Explain that female patients, however, were more likely than male patients to

die or become too sick for transplant.

Explain that the gender disparity likely stems from the formula, based on

objective clinical factors, used in the allocation system. It may actually be a

size disparity.

There was no such gender gap before introduction of the MELD system, which is

based on objective laboratory variables including bilirubin, creatinine, and the

international normalized ratio for prothrombin time.

The MELD formula is intended as a measure of three-month mortality risk.

Dr. Moylan and colleagues cited earlier research suggesting that the formula may

not adequately account for gender differences in the relationship between its

components and mortality risk.

Women's smaller average size may play a role in these differences and affect

allocations in other ways, the researchers said.

For example, children have first priority on livers from pediatric donors, and

livers from large donors cannot always be given to small recipients.

As a result, women may end up waiting longer than men for size-appropriate

livers.

Allocations in the U.S. are now determined exclusively by patients' MELD scores,

regardless of time spent on a waiting list.

The researchers also found that MELD scoring eliminated a racial difference in

the number of patients waiting three years or more for a transplant.

But it had no effect on an existing disadvantage for women, who were and remain

significantly more likely than men to be waitlisted at least three years (OR

0.80 pre-MELD, 0.70 post-MELD, P

[Guest guest]

http://www.medpagetoday.com/Gastroenterology/LiverTransplantation/11918

Disparities in Liver Transplant Allocation Shift but Still Exist

By Gever, Senior Editor, MedPage Today

Published: November 25, 2008

Reviewed by Zalman S. Agus, MD; Emeritus Professor

University of Pennsylvania School of Medicine.

Video source: JAMA

DURHAM, N.C., Nov. 25 -- The objective scoring system adopted in 2002 for

allocating livers for transplantation has put women at a disadvantage, even as

it appears to have eliminated an earlier racial disparity, researchers here

said.

Black patients eligible for liver transplants are no longer more likely than

whites to die or become too ill for the procedure while awaiting a suitable

donor, reported A. Moylan, M.D., of Duke University, and colleagues in

the Nov. 26 issue of the Journal of the American Medical Association.

But after adoption of the MELD (Model for End-Stage Liver Disease) scoring

system in 2002, women became 30% more likely than men to die or become too ill

for transplant (95% CI 8% to 47%). Action Points

--------------------------------------------------------------------------------

Explain to interested patients that the study found that black patients with

end-stage liver disease were no more likely than white patients to die or become

too sick for transplant while waiting for a donor liver.

Explain that female patients, however, were more likely than male patients to

die or become too sick for transplant.

Explain that the gender disparity likely stems from the formula, based on

objective clinical factors, used in the allocation system. It may actually be a

size disparity.

There was no such gender gap before introduction of the MELD system, which is

based on objective laboratory variables including bilirubin, creatinine, and the

international normalized ratio for prothrombin time.

The MELD formula is intended as a measure of three-month mortality risk.

Dr. Moylan and colleagues cited earlier research suggesting that the formula may

not adequately account for gender differences in the relationship between its

components and mortality risk.

Women's smaller average size may play a role in these differences and affect

allocations in other ways, the researchers said.

For example, children have first priority on livers from pediatric donors, and

livers from large donors cannot always be given to small recipients.

As a result, women may end up waiting longer than men for size-appropriate

livers.

Allocations in the U.S. are now determined exclusively by patients' MELD scores,

regardless of time spent on a waiting list.

The researchers also found that MELD scoring eliminated a racial difference in

the number of patients waiting three years or more for a transplant.

But it had no effect on an existing disadvantage for women, who were and remain

significantly more likely than men to be waitlisted at least three years (OR

0.80 pre-MELD, 0.70 post-MELD, P