Abstract

Background: Metabolic dysfunction-associated steatohepatitis (MASH) is the fastest-growing etiology of liver disease for patients with hepatocellular carcinoma (HCC) added to the liver transplantation (LT) waitlist in the US. Patients with MASH-HCC are disproportionately of Hispanic ethnicity, who have historically had poorer access to LT than non-Hispanic (NH) whites. However, it is unclear whether racial and ethnic minorities are waitlisted and transplanted for MASH-HCC at lower-than-expected rates.

Methods: Adults with HCC waitlisted for LT between 1/2015 and 12/2021 were identified in the US Scientific Registry of Transplant Recipients standard analysis file. Patients were included if they (1) had a MASH diagnosis, or (2) had a diagnosis of cryptogenic/idiopathic cirrhosis and body mass index >30 kg/m². Differences between groups were compared using Chi-square, Fisher’s exact, or Kruskal Wallis tests as appropriate. Cox regression modeling was used to determine characteristics associated with having liver transplantation. A p value of <0.05 was considered statistically significant.

Results: Of the 3810 LT candidates, the majority (2713, 71.2%) were NH white. Only 49 (1.1%) were Black, 891 (23.4%) were Hispanic, and 115 (3.0%) were Asian. Most candidates went on to undergo LT, although the proportions of patients receiving LT were significantly different (p=0.001; Figure 1). In pairwise comparisons, Hispanics underwent LT at significantly lower rates than NH whites (p<0.001). Waitlist mortality rates were not significantly different among races/ethnicities (p=0.06). Hispanics received LT at a significantly higher rates in the post-Median MELD at Transplant (MMAT) era (after 6/1/2019) than in the pre-MMAT era (p=0.02). MMAT era did not impact the proportion of patients undergoing LT for other races/ethnicities (all p>0.05). In multivariable Cox regression analysis, Hispanic (HR, 0.85; 95% CI, 0.77-0.95; p=0.002) and Asian (HR, 0.79; 95% CI, 0.63-0.98; p=0.04) patients were significantly less likely to receive LT than NH white patients.

Conclusion: Hispanics and Asians are less likely to receive LT for MASH-HCC than other races/ethnicities. A significantly greater proportion of Hispanic patients had LT in the post-MMAT era, likely reflecting efforts across the country to mitigate access disparities. The proportion of Black patients waitlisted for LT was also surprisingly low. Although there are encouraging trends, work is still needed to address disparities in access to LT for MASH-HCC.