R Rosenblatt et al. Hepatology 2021; 74: 1523-1532. Black Patients Have Unequal Access to Listing for Liver Transplantation in the United States

“It was Feb. 1, 1960, when four black students sat down at Woolworth’s lunch counter in Greensboro, N.C., and ordered coffee” (Time: Why the Woolworth’s Sit-In Worked)

This lunch counter sit-in was a big step in the civil rights movement. The article cited above shows that there is still a lot of work to make sure black patients have equal access to the liver counter too.

Using two databases (CDC WONDER, and UNOS) for 2014-2018, the authors identified 135,367 patients who died of ESLD, 54,734 patients who were listed for transplant, and 26,571 who underwent transplant.

Key findings:

• The national LDR (listing-to-death ratio) was 0.40, significantly lowest in Black patients (0.30), P < 0.001. The highest LDRs clustered in the Northeast and the lowest in the Southeast and Northwest
• The national transplant to listing ratio was 0.48, highest in Black patients (0.53), P < 0.01
• The national transplant to death ratio was 0.20, lowest in Black patients (0.16), P < 0.001

“The most desirable outcome is a high transplant to death ratio—which was present in states like Maryland as well as Georgia, Nebraska, and Wisconsin.” (State values are provided in Tables 1, 3, and 4). Overall, these data show low listing rates for black patients relative to deaths from ESLD. Due to the adoption of MELD score which has objective criteria, the lower transplant rates indicate that Black patients face a disparity in access to liver transplantation.

The authors point out potential roadblocks:

• ESLD first needs to be identified and patient referred to a liver transplant center
• Black patients “were much less likely to understand the LT process”
• Timing is critical, “especially in patients with HCC, which presents a more advanced in Black patients”
• Insurance: “Black patients are more likely to be uninsured or to have public insurance, which is associated with poor access to listing and LT”

My take: This study shows that Black patients face disparities prior to transplant listing. In order to improve outcomes, patients first need to get a seat at the table.

Related blog post: Disparity in the Care of Black Inflammatory Bowel Disease Patients