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Ethnic and Age Disparities in Outcomes Among Liver Transplant Waitlist Candidates

Mustian, Margaux N. MD1; Shelton, Brittany A. MPH1; MacLennan, Paul A. PhD1; Reed, Rhiannon D. MPH1; White, Jared A. MD1; Eckhoff, Devin E. MD1; Locke, Jayme E. MD1; Allman, Richard M. MD2; Gray, Stephen H. MD1

doi: 10.1097/TP.0000000000002523
Original Clinical Science—Liver
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Background. Despite the increasing prevalence of end-stage liver disease in older adults, there is no consensus to determine suitability for liver transplantation (LT) in the elderly. Disparities in LT access exist, with a disproportionately lower percentage of African Americans (AAs) receiving LT. Understanding waitlist outcomes in older adults, specifically AAs, will identify opportunities to improve LT access for this vulnerable population.

Methods. All adult, liver-only white and AA LT waitlist candidates (January 1, 2003 to October 1, 2015) were identified in the Scientific Registry of Transplant Recipients. Age and race categories were defined: younger white (age <60 years), younger AA, older white (age, ≥60 years), and older AA. Outcomes were delisting, transplantation, and mortality and were modeled using Fine and Gray competing risks.

Results. Among 101 805 candidates, 58.4% underwent transplantation, 14.7% died while listed, and 21.4% were delisted. Among those delisted, 36.1% died, whereas 7.4% were subsequently relisted. Both older AAs and older whites were more likely than younger whites to be delisted and to die after delisting. Older whites had higher incidence of waitlist mortality than younger whites (subdistribution hazard ratio, 1.07; 95% confidence interval, 1.01-1.13). All AAs and older whites had decreased incidence of LT, compared with younger whites.

Conclusions. Both older age and AA race were associated with decreased cumulative incidence of transplantation. Independent of race, older candidates had increased incidences of delisting and mortality after delisting than younger whites. Our findings support the need for interventions to ensure medical suitability for LT among older adults and to address disparities in LT access for AAs.

1 Division of Transplantation. Department of Surgery, University of Alabama at Birmingham, Birmingham, AL.

2 Department of Medicine, George Washington University School of Medicine, Washington, DC.

Received 8 June 2018. Revision received 26 October 2018.

Accepted 31 October 2018.

The project described was supported by Award Number P30AG031054 from the NIH. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute Aging or the National Institutes of Health.

This project was also supported by the National Institutes of Health (NIH)- National Research Service Award, through Grant Award Number T32 DK007545 (PI Mustian, mentored) from the NIH. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

The authors declare no conflicts of interest.

M.M. participated in the writing of the article, data analysis, and research design. B.S. participated in data analysis, research design, writing of the article, contributed analytic tools. P.M.L. participated in research design and critical revision of the article. R.R. participated in research design and critical revision of the article. J.W. participated in research design and critical revision of the article. D.E. participated in research design and critical revision of the article. J.L. participated in research design and critical revision of the article. R. M.A. participated in research design, participated in critical revision of the article. S.G. participated in research design, participated in writing of the article, participated in the performance of research.

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 (www.transplantjournal.com).

Correspondence: Stephen H Gray, MD, 1720 2nd Ave South, LHRB 728A, Birmingham, AL 35294-0007. (sgray@uabmc.edu).

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