Racial Disparities in Candidates for Hepatocellular Carcinoma Liver Transplant After 6-Month Wait Policy Change

Abstract

ImportanceRacial disparities in liver transplant (LT) for hepatocellular carcinoma (HCC) may be associated with unequal access to life-saving treatment.ObjectiveTo quantify racial disparities in LT for HCC and mortality after LT, adjusting for demographic, clinical, and socioeconomic factors.Design, Setting, and ParticipantsThis cohort study was a retrospective analysis of United Network Organ Sharing/Organ Procurement Transplant Network (OPTN) data from 2003 to 2021. Participants were adult patients with HCC on the LT waiting list and those who received LT. Data were analyzed from March 2022 to September 2023.ExposuresRace and time before and after the 2015 OPTN policy change.Main Outcomes and MeasuresProportion of LT from wait-listed candidates, the proportion of waiting list removals, and mortality after LT.ResultsAmong 12 031 patients wait-listed for LT with HCC (mean [SD] age, 60.8 [7.4] years; 9054 [75.3%] male; 7234 [60.1%] White, 2590 [21.5%] Latinx/o/a, and 1172 [9.7%] Black or African American), this study found that after the 2015 model of end-stage liver disease (MELD) exception policy changes for HCC (era 2), the overall proportion of LT for HCC across all races decreased while the proportion of dropouts on the LT waiting list remained steady compared with patients who did not have HCC. In Kaplan-Meier analysis, Asian patients demonstrated the lowest dropout rates in both era 1 and era 2 (1-year dropout, 16% and 17%, respectively; P < .001). In contrast, Black or African American patients had the highest dropout rates in era 1 (1-year dropout, 24%), but comparable dropout rates (23%) with White patients (23%) and Latinx/o/a patients in era 2 (23%). In both eras, Asian patients had the highest survival after LT (5-year survival, 82% for era 1 and 86% for era 2), while Black or African American patients had the worst survival after LT (5-year survival, 71% for era 1 and 79% for era 2). In the multivariable analysis for HCC LT recipients, Black or African American race was associated with increased risk of mortality in both eras, compared with White race (HR for era 1, 1.17; 95% CI, 1.05-1.35; and HR for era 2, 1.31; 95% CI, 1.10-1.56).Conclusions and RelevanceThis cohort study of LT candidates in the US found that after the 2015 MELD exception policy change for HCC, the proportion of LT for HCC had decreased for all races. Black or African American patients had worse outcomes after LT than other races. Further research is needed to identify the underlying causes of this disparity and develop strategies to improve outcomes for HCC LT candidates.

Racial–ethnic differences in liver transplant waitlist outcomes in patients with hepatocellular carcinoma before and after recent changes to allocation policy

“…20,21 The authors hypothesized that this was due to Asian patients having a higher risk of suffering from simultaneous HBV infections, having lower MELD scores and more compensated status of liver disease. 22 In our study, of all 253 patients listed with positive HBV serology in the timeframe of the study, 65% were Asian. In addition, nearly 53% of all waitlisted Asian HCC LT candidates had positive HBV serology, which raises further suspicion that a comorbid HBV infection may have contributed to the finding.…”

“…reported that Asian LT candidates with HCC had the lowest waitlist removal rates in more contemporary eras. The authors hypothesized that this was due to Asian patients having a higher risk of suffering from simultaneous HBV infections, having lower MELD scores and more compensated status of liver disease 22 . In our study, of all 253 patients listed with positive HBV serology in the timeframe of the study, 65% were Asian.…”