Department of Surgery, Massachusetts General Hospital, Boston, MA.
Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.
Ann Surg. 2024 Jan 1;279(1):112-118. doi: 10.1097/SLA.0000000000005933. Epub 2023 Jun 27.
To determine the association of sex with access to liver transplantation among candidates with the highest possible model for end-stage liver disease score (MELD 40).
Women with end-stage liver disease are less likely than men to receive liver transplantation due in part to MELD's underestimation of renal dysfunction in women. The extent of the sex-based disparity among patients with high disease severity and equally high MELD scores is unclear.
Using national transplant registry data, we compared liver offer acceptance (offers received at match MELD 40) and waitlist outcomes (transplant vs death/delisting) by sex for 7654 waitlisted liver transplant candidates from 2009 to 2019 who reached MELD 40. Multivariable logistic and competing-risks regression was used to estimate the association of sex with the outcome and adjust for the candidate and donor factors.
Women (N = 3019, 39.4%) spent equal time active at MELD 40 (median: 5 vs 5 days, P = 0.28) but had lower offer acceptance (9.2% vs 11.0%, P < 0.01) compared with men (N = 4635, 60.6%). Adjusting for candidate/donor factors, offers to women were less likely accepted (odds ratio = 0.87, P < 0.01). Adjusting for candidate factors, once they reached MELD 40, women were less likely to be transplanted (subdistribution hazard ratio = 0.90, P < 0.01) and more likely to die or be delisted (subdistribution hazard ratio = 1.14, P = 0.02).
Even among candidates with high disease severity and equally high MELD scores, women have reduced access to liver transplantation and worse outcomes compared with men. Policies addressing this disparity should consider factors beyond MELD score adjustments alone.
确定在最高可能的终末期肝病模型评分（MELD40）的候选者中，性别与获得肝移植的关联。
女性终末期肝病患者接受肝移植的可能性低于男性，部分原因是 MELD 低估了女性的肾功能不全。在疾病严重程度高且 MELD 评分同样高的患者中，性别差异的程度尚不清楚。
利用国家移植登记数据，我们比较了 2009 年至 2019 年期间达到 MELD40 的 7654 名等待肝移植的候选者中，性别在肝移植接受（在匹配 MELD40 时收到的肝源）和等待名单结果（移植与死亡/退出）之间的差异。多变量逻辑和竞争风险回归用于估计性别与结果的关联，并调整候选者和供体因素。
女性（N=3019，39.4%）在 MELD40 时的活跃时间相等（中位数：5 天对 5 天，P=0.28），但接受的肝源较少（9.2%对 11.0%，P<0.01）。调整候选者/供体因素后，女性获得的肝源不太可能被接受（比值比=0.87，P<0.01）。调整候选者因素后，一旦达到 MELD40，女性接受移植的可能性较小（亚分布风险比=0.90，P<0.01），死亡或被取消资格的可能性较大（亚分布风险比=1.14，P=0.02）。
即使在疾病严重程度高且 MELD 评分同样高的候选者中，女性获得肝移植的机会也比男性少，结局也比男性差。解决这种差异的政策应考虑除 MELD 评分调整之外的因素。
