The Impact of Primary Liver Disease and Social Determinants in a Mixed Donor Liver Transplant Program: A Single‐Center Analysis

Abstract

Organ allocation in liver transplantation (LT) remains imperfect. Periodic center reviews ensure programs transparently evaluate the impact of practice on access to transplantation, reflecting, in particular, patient (primary disease, social determinants) and program (deceased versus live donation) factors. Adult Ontario residents waitlisted for first LT at Toronto General Hospital from November 2012 to May 2019 were reviewed. Analyses were performed between distance to transplant center, income, education level, population density and primary liver disease, with LT, deceased donor liver transplant (DDLT), living donor liver transplant (LDLT), and delisting. Of 1735 listed patients, 549 were delisted (32%), while 1071 were transplanted (62%), with 819 DDLT recipients (76%) and 252 LDLT recipients (24%), while 115 (7%) remained actively listed at data census. On univariate analysis, DDLT recipients lived 30% closer (median 39.7 versus 60.6 km; P < 0.001), lived in more populous areas (median 8501.0 versus 6868.5 people in a 1‐km radius; P < 0.001), and resided in households that annually earned 10% less (median $92,643.17 versus $102,820.89 Canadian dollars; P < 0.001) compared with LDLT recipients. These findings with population density and income differences between DDLT versus LDLT receival remained significant on multivariate modeling even when accounting for primary liver disease. Primary liver disease was a statistically significant factor on multivariate analyses in LT receival (P = 0.001) as well as DDLT versus LDLT receival (P < 0.001). Of patients listed for end‐stage liver disease, more patients with autoimmune cholestatic liver diseases received LDLT (34%‐41%) than DDLT (27%‐30%); this contrasted with patients with noncholestatic diseases LDLT (8%‐19%) versus DDLT (37%‐59%) receival (P < 0.001). Review of transplant allocation in a large mixed‐donor North American liver transplant program demonstrates how patient social determinants and primary liver disease etiology continue to be significantly associated with ultimate transplantation.

Long‐term Outcomes of Pediatric Living Versus Deceased Donor Liver Transplantation Recipients: A Systematic Review and Meta‐analysis

“…Recent Canadian data showed that adult patients with DDLT were more likely to live in urban areas and be in a household that earned less income compared with LDLT recipients. (39) Although pediatric data are lacking, the clearly superior pediatric outcomes of LDLT may be used as a tool to encourage the development of infrastructure and health care systems to support living donation in marginalized and low-income areas.…”

Survival After Liver Transplantation: An International Comparison Between the United States and the United Kingdom in the Years 2008–2016

“…In addition, a number of factors that may be related to the post-LT outcome were not available, including medication coverage, detailed information about comorbidities, geographical distance to a transplantation center, and socioeconomic status. 44 Regarding HCV patients, direct-acting antiviral (DAA) therapy became widely available in 2014 in the United States. 45 In the United Kingdom, the early access program of DAA therapy began in 2014.…”

Are MELD and MELDNa Still Reliable Tools to Predict Mortality on the Liver Transplant Waiting List?

“…163,188,189 A strong culture supporting live donation should be implemented, building full-time living donation teams, supporting living donors financially, and raising awareness among the general public. 105…”

“…The authors suggest that it may be because of universal healthcare availability, allowing for listing and delisting to be based on disease severity alone. 105…”

“…However, socioeconomic characteristics of patients with a potential live donor (younger, married, nonimmigrant, English as a first language, higher income) may limit the generalization of this type of transplant in Western countries. 105,186 Taking unpaid time off work is a significant barrier preventing people of lower socioeconomic status from living donor LT (LDLT) in certain countries, such as the United States. There is evidence of decreased access to LDLT for African American and Hispanic patients.…”