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Racial/Ethnic Disparities in Access and Outcomes of Simultaneous Liver-Kidney Transplant Among Liver Transplant Candidates With Renal Dysfunction in the United States

Chang, Su-Hsin PhD, SM1; Wang, Mei MS1; Liu, Xiaoyan MS2; Alhamad, Tarek MD3; Lentine, Krista L. MD, PhD4; Schnitzler, Mark A. PhD4; Colditz, Graham A. MD, DrPH1; Park, Yikyung ScD1; Chapman, William C. MD5

doi: 10.1097/TP.0000000000002574
Original Clinical Science—Liver

Background. Since the Model for End-stage Liver Disease (MELD) allocation system was implemented, the proportion of simultaneous liver-kidney transplantation (SLKT) has increased significantly. However, whether racial/ethnic disparities exist in access to SLKT and post-SLKT survival remains understudied.

Methods. A retrospective cohort of patients aged ≥18 years with renal dysfunction on the liver transplant (LT) waiting list was obtained from Organ Procurement and Transplantation Network. Renal dysfunction was defined as estimated glomerular filtration rate <60 mL/min/1.73 m2 at listing for LT. Multilevel time-to-competing-events regression adjusting for center effect was used to examine the likelihood of receiving SLKT. Inverse probability of treatment weighted survival analyses were used to analyze posttransplant mortality outcomes.

Results. For patients with renal dysfunction at listing for LT, not listed for simultaneous kidney transplant, non-Hispanic black (NHB) and Hispanic patients were more likely to receive SLKT than non-Hispanic white (NHW) patients (NHB: multivariable-adjusted hazard ratio [aHR] 2.57; 95% confidence interval [CI], 1.42-4.65; Hispanic: aHR, 2.03; 95% CI, 1.14-3.60). For post-SLKT outcomes, compared to NHW patients, NHB patients had a lower mortality risk before 24 months (aHR, 0.80; 95% CI, 0.65-0.97) but had a higher mortality risk (aHR, 2.00; 95% CI, 1.59-2.55) afterward; in contrast, Hispanic patients had a lower overall mortality risk than NHW patients (aHR, 0.61; 95% CI, 0.51-0.74).

Conclusions. In the MELD era, racial/ethnic differences exist in access and survival of SLKT for patients with renal dysfunction at listing for LT. Future studies are warranted to examine whether these differences remain in the post-SLK allocation policy era.

1 Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO.

2 Department of Biostatistics, Boston University School of Public Health, Boston, MA.

3 Division of Nephrology, Department of Internal Medicine, Washington University School of Medicine, St Louis, MO.

4 Center for Abdominal Transplantation, Saint Louis University, St Louis, MO.

5 Section of Abdominal Transplantation, Department of Surgery, Washington University School of Medicine, St Louis, MO.

Received 10 April 2018. Revision received 21 November 2018.

Accepted 30 November 2018.

The authors declare no conflicts of interest.

This research was supported by the Foundation for Barnes-Jewish Hospital. S.-H.C. is supported by the Agency for Healthcare Research and Quality (grant K01 HS022330) and the National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases (grant R21 DK110530).

S.-H.C. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S.-H.C., Y.P., and W.C.C. studied the concept and designed the work. All authors participated in the analysis and interpretation of data for the work. S.-H.C. drafted the article. All authors participated in the critical revision of the article for important intellectual content. S.-H.C., M.W., and X.L. provided statistical expertise for this work. S.-H.C. obtained funding. S.-H.C., G.A.C., and W.C.C. provided administrative, technical, or material support. S.-H.C., T.A., K.L.L., M.A.S., G.A.C., Y.P., and W.C.C. participated in study supervision.

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Correspondence: Su-Hsin Chang, PhD, SM, Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8100, St Louis, MO 63110. (

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