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From the Journals

Sex and Size Gaps Persisted in HCC Liver Transplants

Despite recent allocation changes, women with hepatocellular carcinoma faced an 8% lower chance of receiving a liver transplant and a 6% higher risk of death or delisting compared to men, with size differences playing a significant role.

Conexiant

A study revealed sex-based disparities in access to liver transplantation for patients with hepatocellular carcinoma. The research found that women were less likely to receive a deceased-donor liver transplant and more likely to die or be removed from the waiting list compared with men.

In the retrospective cohort study, published in JAMA Surgery, investigators analyzed the data of 31,725 adult liver transplant candidates with hepatocellular carcinoma (HCC) exception scores between January 1, 2010, and March 2, 2023.

The study utilized data from the Scientific Registry of Transplant Recipients (SRTR), including all adult wait-listed liver transplant candidates receiving HCC exception scores. Competing-risks regression models were used to estimate the association of female sex with DDLT and death or waiting list removal.

The cohort comprised 7,520 female (23.7%) and 24,205 male (76.3%) candidates with a mean age of 61.2 years. The racial and ethnic breakdown was 7.6% Asian, 9.0% Black, 81.9% White, and 1.5% other race, with 18.8% identifying as Latinx. Insurance types included 48.7% commercial, 30.9% Medicare, 14.6% Medicaid, and 4.8% Veterans Affairs or government.

Women were shorter (mean 160.7 cm vs 175.3 cm) and lighter (mean 76.1 kg vs 89.9 kg) than men. The mean allocation MELD score at listing was 13.0 (standard deviation [SD] = 5.7), and the mean calculated MELD score was 11.2 (SD = 4.2).

Among the key findings were:

  • Women had an 8% lower incidence of deceased-donor liver transplants (DDLT) (subdistribution hazard ratio [HR] = 0.92, 95% confidence interval [CI] = 0.89–0.95, P < .001) and a 6% higher incidence of death or waiting list removal (subdistribution HR = 1.06, 95% CI = 1.00–1.13, P = .04) compared with men.
  • The disparity was largely explained by candidate size differences, but shorter women (< 166 cm) still had lower transplant rates compared with shorter men (subdistribution HR = 0.93, 95% CI = 0.88–0.99, P = .03).
  • Women had a lower 1-year cumulative incidence of DDLT (50.8% vs 54.0%, P < .001) and a higher 1-year cumulative incidence of death or delisting (16.2% vs 15.0%, P = .002) compared with men.

Waiting list outcomes showed that 60.0% of women vs 62.2% of men received a transplant. Mortality rates were 6.7% for women vs 5.4% for men, while 13.3% of women vs 13.0% of men were removed for being too sick.

The median time from listing to transplant was 223 days for women vs 213 days for men. At transplant, the mean allocation MELD was 26.5 for women vs 26.3 for men, and the mean calculated MELD was 13.4 for women vs 13.1 for men.

Donor characteristics for women vs men included:

  • Mean donor height: 167.5 cm vs 172.3 cm
  • Mean donor weight: 75.6 kg vs 85.3 kg
  • Mean donor risk index: 1.8 vs 1.7
  • Mean donor age: 43.8 years vs 44.0 years
  • Proportion receiving DCD livers: 9.3% vs 9.9%
  • Proportion receiving livers with macrosteatosis ≥ 30%: 8.2% vs 9.0%.

Among transplant candidates who died or were delisted, women had higher MELD scores compared with men (allocation MELD = 25.0 vs 23.8, calculated MELD = 24.1 vs 22.5). The median time from listing to death was longer among women (204 days vs 186 days) compared with men. The most common causes of death for women vs men were multisystem organ failure (25.4% vs 21.3%) and infection (13.6% vs 11.8%).

The study analyzed outcomes across different allocation policy periods. Female sex was associated with decreased DDLT in periods 1 (subdistribution HR = 0.89, 95% CI = 0.85–0.94, P < .001), 3 (subdistribution HR = 0.84, 95% CI = 0.72–0.98, P = .03), and 4 (subdistribution HR = 0.90, 95% CI = 0.82–0.97, P = .01). Female sex was associated with increased death or delisting only in period 1 (subdistribution HR = 1.13, 95% CI = 1.03–1.23, P = .008).

Posttransplant outcomes favored women, who had lower mortality compared to men (HR = 0.82, 95% CI = 0.75–0.89, P < .001) after adjusting for candidate factors including size. The survival benefit for women became apparent beyond 2 years posttransplant. Recurrence of HCC as a cause of death was lower in women (22.8% vs 29.2%, P < .001).

Size analysis revealed that 27.6% of the cohort (but 77.9% of women) were shorter than 166 cm. Independent of sex, shorter height (< 166 cm) was associated with decreased DDLT (subdistribution HR = 0.93, 95% CI = 0.90–0.96, P < .001) and increased death or delisting (subdistribution HR = 1.07, 95% CI = 1.01–1.14, P = .02).

One author reported receiving personal fees from Tegus outside the submitted work. No other disclosures were reported.