EDITORIAL Editorials represent the opinions

of the authors and JAMA and

not those of the American Medical Association.

Race and Sex Disparities

in Liver Transplantation
Progress Toward Achieving Equal Access?
David A. Axelrod, MD, MBA tem contributed to a reduction in the waiting list death rates
from 150 to 125 deaths per 1000 patient-years at risk.1 How-
Elizabeth A. Pomfret, MD, PhD
ever, these waiting list death rates had been declining for
the 5 years before MELD at an even greater rate. Further-

U
NIQUE AMONG MEDICAL SPECIALTIES, THE ORGAN
more, this reduction in waiting list death rates was accom-
transplantation community has the obligation to ex-
plished without a significant deterioration in posttrans-
plicitly allocate a very limited lifesaving resource.
plant survival. The MELD system has also led to a more
Liver transplantation offers the sole hope for long-
objective method for estimating the benefit of transplant and
term survival for patients with end-stage liver disease. Over-
subsequent revision of the allocation system. For relatively
all survival rates for transplantation now routinely exceed 90%
healthy patients (MELD score of ⬍15), liver transplanta-
at 1 year, even among patients with the most advanced liver
tion was found to have no survival benefit and was in fact
failure, the majority of whom would die within months with-
associated with worse survival than remaining on the trans-
out a transplant.1,2 As stewards of a precious resource, the trans-
plant list.5 As a result, the transplant community has re-
plant community has a goal of achieving an equitable, trans-
quired that donated livers be used within a wider geographi-
parent, and efficient system of organ allocation. Meeting these
cal region before being used in the local community if no
goals is crucial for maintaining confidence in the transplant
recipients with a MELD score of more than 15 are waiting
system and encouraging organ donation.
locally.
Before 2002, deceased donor liver allografts were allo-
In this issue of JAMA, Moylan and colleagues6 report that
cated by using a system that was loosely based on severity of
the use of MELD has had another desirable benefit. Retro-
illness and time spent waiting. Review of the national out-
spective analysis of the United Network for Organ Sharing
comes demonstrated that this system consistently failed to
(UNOS) database confirmed prior findings that in the pre-
achieve the goals of equity, transparency, and efficiency.3,4 Liver
MELD era, black patients were more likely to die on the wait-
allocation was perceived to be too arbitrary, too easily ma-
ing list than white patients.7 The article by Moylan et al shows
nipulated, and overly reliant on waiting time. Furthermore,
that following MELD, there were no significant racial or eth-
major regional differences were found in the rates of patient
nic differences in time waiting or waiting list deaths. This
death while on the waiting list. To address these issues, the
finding represents an important improvement in the eq-
Institute of Medicine (IOM) recommended to the US Depart-
uity of the organ allocation system. However, Moylan et al
ment of Health and Human Services that a novel system of
also identified a persistent disparity between women and men
organ allocation be defined based solely on medical criteria.3
in access to liver transplantation.
In response, the transplant community developed and imple-
The reduction in waitlist mortality for black patients is
mented the current system of liver allocation that prioritizes
likely multifactorial and may in fact not guarantee an equal
patients on the basis of severity of illness, as assessed by the
opportunity to obtain a liver transplant. The transplant pro-
Model of End-Stage Liver Disease (MELD) score. The MELD
cess requires a complex pretransplant evaluation. Before
score is calculated by using 3 laboratory test results (creati-
MELD, early referral for evaluation often resulted in more
nine, bilirubin, and international normalized ratio), which are
rapid listing and a correspondingly greater opportunity to
objective measures of the degree of organ dysfunction and risk
accrue waiting time before clinical decompensation. Be-
of death. Under the MELD allocation system, the patient with
cause patients without private health insurance are signifi-
the greatest chance of dying without a transplant is allocated
cantly less likely to be referred for specialist care, they were
the next available organ regardless of the time the patient has
spent on the waiting list. Author Affiliations: Department of Surgery, Dartmouth-Hitchcock Medical Cen-
The clinical benefits of the MELD allocation system have ter, Lebanon, New Hampshire (Dr Axelrod); and Department of Transplantation,
been well documented. Implementation of the MELD sys- Division of Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts
(Dr Pomfret).
Corresponding Author: David A. Axelrod, MD, MBA, Department of Surgery,
See also p 2371. Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756
(david.axelrod@hitchcock.org).

©2008 American Medical Association. All rights reserved. (Reprinted) JAMA, November 26, 2008—Vol 300, No. 20 2425

Downloaded from jama.ama-assn.org at Vanderbilt University on November 7, 2011

EDITORIAL
often evaluated and listed too late. Under MELD, late list-
ing does not preclude transplantation as it often did in the
system based on waiting time. However, as demonstrated
by Moylan et al, black patients are still listed with higher
MELD scores and for a shorter period, suggesting that the
access barriers remain even under the new system. In ad-
dition, black patients continue to have a higher rate of liver
disease than the national average, but represent a smaller
proportion of transplant recipients. Thus, it is likely that many
black patients are never listed due to advanced disease at
presentation as a result of late referral. This problem is out-
side of the scope of the allocation system, however, and needs
a broader solution.
The sex disparity is likely a reflection of several factors,
including a limitation in the MELD calculation, body and
organ size considerations, and potentially differences in the
etiology of the underlying liver disease. Because women have
less body mass, the inclusion of creatinine rather than weight-
adjusted glomerular filtration rate in the MELD score is likely
to underestimate their degree of renal dysfunction. Thus,
MELD scores will be lower in women than in men with the
same degree of renal failure, decreasing women’s access to
liver allografts. Women are also smaller, limiting the pool
of available organs. Women may wait longer for a size-
appropriate organ because livers from pediatric donors are
preferentially allocated to children awaiting transplanta-
tion. In addition, a small organ can be used in a larger in-
dividual, but the converse is not always possible. More-
over, women are more likely than men to have autoimmune
liver diseases, including primary biliary cirrhosis and pri-
mary sclerosing cholangitis, both of which are less likely than
hepatitis C to lead to kidney dysfunction and higher MELD
scores. From the data presented by Moylan et al, it appears
logical to adjust the MELD score based on sex to ensure that
the risk of death is comparable for men and women who
have the same MELD score. Consideration should also be
given to expanding access to pediatric donors for women
who are less than a certain weight or size.
Although MELD has reduced the disparity based on some
demographic characteristics, it has not met the IOM direc-
tive to reduce geographic disparity. Under existing prac-
tice, the nation is divided into 11 regions by UNOS, each of
which is composed of 1 or more donation service areas
(DSAs). These regions vary substantially in terms of popu-
lation size and number of deceased donors. In the analysis
by Moylan et al, as well as many other studies, survival with
end-stage liver disease is determined in large part by where
the patient lives, not by the patient’s race or sex. As in poli-
tics, right now, all allocation is local. Patients who live in
(or have the money to travel to) regions with a higher ratio
of donors to transplant candidates can receive organ trans-
plants far earlier and at a lower MELD score.8 The disparity
is even greater at the DSA level. In small DSAs, the percent-
age of recipients who receive transplants at low MELD scores
(11-18) was 47% compared with only 23% in large DSAs
2426 JAMA, November 26, 2008—Vol 300, No. 20 (Reprinted)
Downloaded from jama.ama-assn.org at Vanderbilt University on November 7, 2011
(P⬍ .001).9 This difference directly correlates into a higher
death rate on the waiting list. By adjusting for these re-
gional differences, Moylan et al6 may have diminished the
ongoing disparity in access for black patients who are largely
concentrated in larger urban areas with longer waiting times.
It is likely that women, especially those who are often less
able to travel due to other responsibilities and those with-
out health insurance, are likewise systematically less able
to access this lifesaving resource.
When compared with the system before 2002, the cur-
rent MELD system is clearly a step toward achieving the goal
of an equitable, efficient, and transparent organ allocation
system. The MELD system appears to have reduced, but likely
not eliminated, differential access based on race and eth-
nicity. However, modest differences based on sex persist,
but could be addressed by revisions in the organ allocation
policy to ensure that MELD scores are comparable across
sexes. The real challenge facing the liver transplant com-
munity is to tackle the long-standing disparity of geogra-
phy. If those who can afford to travel can receive organ trans-
plants at lower MELD scores more rapidly, the system will
remain fundamentally inequitable.10 The current construc-
tion of DSAs and UNOS regions is largely an accident of his-
tory. As recognized by the IOM, achieving the goals of or-
gan allocation requires the creation of equivalent size regions
to match supply and demand. The transplant community
should be acknowledged for the progress achieved thus far
in reducing racial and sex disparities, and should be en-
couraged to take the next difficult step in further reducing
geographic disparities.
Financial Disclosures: None reported.
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©2008 American Medical Association. All rights reserved.