Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
Transplant Surgery, Mayo Clinic, Rochester, MN.
Transplantation. 2018 Oct;102(10):1710-1716. doi: 10.1097/TP.0000000000002196.
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.
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.
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.
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.
肝移植（LT）中存在基于性别的差异，但这种差异的原因尚不完全清楚。本研究旨在评估身高、终末期肝病模型（MELD）、MELD-Na 和例外积分在 LT 机会差异中的作用。
本研究纳入了 2002 年至 2013 年期间在器官获取和移植网络（Organ Procurement and Transplantation Network）登记接受 LT 的成年人。采用 Cox 比例模型分析与 LT 可能性相关的协变量。在另一组接受碘酞酸盐清除率测定肾小球滤过率（glomerular filtration rate，GFR）的登记成年人队列中（n=611），我们确定了所有 GFR 范围内男性和女性之间肌酐衍生 MELD 点的数量。还对女性 MELD 评分缺陷的校正对 LT 的影响进行了建模。
在 90720 名器官获取和移植网络登记人中，女性的死亡率高于男性（列入名单后 4 年：22% vs. 18%，P＜0.0001），LT 的可能性也较低（49% vs. 58%，P＜0.0001）；女性的移植率低 20%（风险比，0.80；95%置信区间，0.78-0.81）。身高和 MELD 例外评分的差异解释了女性 LT 不足的大部分原因（风险比，0.91；95%置信区间，0.89-0.94）。女性的肌酐衍生 MELD 点比肾功能相似的男性少 1-2.4 个。MELD-Na 使性别差异恶化。女性增加 1 或 2 个 MELD 点显著影响 LT 的机会。
身高和 MELD 例外评分的差异解释了 LT 中基于性别的差异的大部分原因。此外，MELD 评分对女性疾病严重程度的低估最多可达 2.4 分，MELD-Na 加剧了这种差异。基于 MELD 的低估程度对分配有重大影响。
