The fundamentals of sex‐based disparity in liver transplantation: Understanding can lead to change

Abstract

Liver transplantation (LT) is the definitive treatment for end‐stage liver disease. Unfortunately, women are disadvantaged at every stage of the LT process. We conducted a literature review to increase the understanding of this disparity. Hormonal differences, psychological factors, and Model for End‐Stage Liver Disease (MELD) score inequalities are some pretransplantation factors that contribute to this disparity. In the posttransplantation setting, women have differing risk than men in most major outcomes (perioperative complications, rejection, long‐term renal dysfunction, and malignancy) and assessing the two groups together is disadvantageous. Herein, we propose interventions including standardized criteria for LT referral, using an alternate MELD, education for support of women, and motivating women to seek living donors. Understanding sex‐based differences will allow us to improve access, tailor management, and improve overall outcomes for all patients, particularly women.

Revising the MELD Score to Address Sex-Bias in Liver Transplant Prioritization for a German Cohort

“…Furthermore, several publications have discussed the influence of the post-menopausal hormonal status on the decreased access of women to liver transplantation. Oestrogens have a potentially protective role in the progression of liver fibrosis, which can lead to liver cirrhosis and the need for liver transplantation [ 25 ]. This protection is lost during menopause [ 25 ].…”

“…Oestrogens have a potentially protective role in the progression of liver fibrosis, which can lead to liver cirrhosis and the need for liver transplantation [ 25 ]. This protection is lost during menopause [ 25 ]. In addition to the physiological factors mentioned above, social factors also play a significant role, such as a generally reduced evaluation and consideration for liver transplantation among women [ 26 ].…”

Addressing sex-based disparities in liver transplantation

“…In an analysis of over 150 000 patients listed for liver transplantation from 1995 to 2012, women were 4.8% less likely to undergo transplantation and less commonly received exception points compared with men [12 ▪▪ ]. This discrepancy has been attributed to sex differences in HCC prevalence, as HCC accounts for the majority of MELD exception points and is two to four times more common in men [14,15 ▪▪ ]. However, in a study of 14 844 patients with HCC listed for liver transplantation with MELD exception points between 2005 and 2014, women in mid-UNOS wait regions (but not short or long) were significantly less likely to receive liver transplantation than men [16].…”

“…Although the prevalence of NAFLD was 19% lower in women than men in a large meta-analysis, women with NAFLD were at similar risk for NASH [21 ▪ ]. Furthermore, postmenopausal women have a significantly higher risk of advanced fibrosis because of loss of the protective effect of estrogen [15 ▪▪ ,21 ▪ ]. Despite being 50% more likely to be listed for liver transplantation for NASH, women are less likely to receive liver transplantation [22].…”

More than a few good women: honoring the ladies of the liver

“…[15] As highlighted in the current AASLD Women's History Month collection found at: aasldjournals.com, gender and racial disparities are well documented in liver transplantation. [16] A recent comprehensive review article by Singh et al [17] demonstrates a pervasive sex-based disparity in liver transplantation that disadvantages women throughout the entire process of transplantation. As Ge et al [18] further highlighted this past year, although we have defined the problem of disparity in access and outcomes in liver transplantation, the next critical step "will involve thoroughly investigating the social determinants of health factors that disproportionately impact populations affected by disparities in transplantation.…”