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Reduced Access to Liver Transplantation in Women

Role of Height, MELD Exception Scores, and Renal Function Underestimation

Allen, Alina M., MD1; Heimbach, Julie K., MD2; Larson, Joseph J.3; Mara, Kristin C.3; Kim, W. Ray, MD4; Kamath, Patrick S., MD1; Therneau, Terry M., PhD3

doi: 10.1097/TP.0000000000002196
Original Clinical Science—Liver

Background Sex-based disparities in liver transplantation (LT) are incompletely understood. We assessed the role of height, Model for End-Stage Liver Disease (MELD), MELD-Na, and exception points in the disparate access to LT.

Methods Adults waitlisted for LT at Organ Procurement and Transplantation Network between 2002 and 2013 were included. Covariates associated with likelihood of LT were analyzed by Cox proportional model. In a separate cohort of waitlisted adults with glomerular filtration rate measurement by iothalamate clearance (n = 611), we determined the number of creatinine-derived MELD points in men versus women, across all ranges of glomerular filtration rate. The impact of correcting the MELD score deficit in women on LT was modeled.

Results Among 90 720 Organ Procurement and Transplantation Network registrants, women had higher mortality than men (4 years after listing: 22% vs 18%, P < 0.0001), and lower likelihood of LT (49% vs 58%, P < 0.0001); women were 20% less likely to be transplanted (hazard ratio, 0.80; 95% confidence interval, 0.78-0.81). Differences in height and MELD exception scores accounted for most of the LT deficit in women (hazard ratio, 0.91; 95% confidence interval, 0.89-0.94). Women received between 1 and 2.4 fewer creatinine-derived MELD points than men with similar renal dysfunction. MELD-Na worsened the gender disparity. Addition of 1 or 2 MELD points to women significantly impacted LT access.

Conclusions Differences in height and MELD exception points explained most of the sex-based disparity in LT. Additionally, MELD score underestimated disease severity in women by up to 2.4 points and MELD Na exacerbated this disparity. The degree of underestimation based on MELD had significant impact on allocation.

Based on an analysis of the Organ Procurement and Transplantation Network (OPTN) between 2002 and 2013, the authors confirm that women are systematically disadvantaged compared to men in their access to liver transplantation further shedding light into potential steps the transplant community should take.

1 Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.

2 Transplant Surgery, Mayo Clinic, Rochester, MN.

3 Biostatistics and Informatics, Mayo Clinic, Rochester, MN.

4 Gastroenterology and Hepatology, Stanford University, Stanford, CA.

Received 26 October 2017. Revision received 18 February 2018.

Accepted 12 March 2018.

Grant support from National Institute of Diabetes and Digestive and Kidney Diseases DK-34238, DK-92336 (WRK).

The authors declare no conflicts of interest.

A.M.A., W.R.K., P.S.K. participated in the study concept and design. J.J.L. participated in the acquisition of data. J.J.L., K.C.M., T.M.T. participated in the statistical analysis. A.M.A., J.K.H., W.R.K., P.S.K., and T.M.T. participated in the analysis and interpretation of data. AMA participated in the drafting of the article. J.K.H., W.R.K., P.S.K., and T.M.T. participated in the critical revision of the article for important intellectual content.

Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Correspondence: Alina M. Allen, MD, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. (

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