Abstract

Background:

Despite liver transplant (LT) waitlist prioritization being based on model for end stage liver disease (MELD) score, situations arise when patients are not optimally represented: 1) “inactive” and 2) lower MELD due to missing MELD “recertification”. LT candidates are required to update, or “recertify”, their labs within a certain amount of time based on their MELD (e.g., MELD ≥25 requires recertification by 7 days or MELD decreases to last lower value and then to 6 if missed again). Also, patients become inactive for many reasons, some related to waitlist maintenance, and inactive status is associated with higher waitlist mortality. Social determinants of health may disproportionally impact patients leading to racial disparities in recertifying MELD and remaining active. We aimed to examine the association between race/ethnicity and these sub-optimal states.

Methods:

We studied national registry data (SRTR) on adult, first-time LT waitlist registrants 1/2017-9/2022. Patients who ever received MELD exception points or were classified as Status 1 were excluded. For Model 1, the outcome event was defined as ever missing lab recertification or being inactive due to “candidate cannot be contacted”, “candidate work-up not complete”, “insurance issues”, or “medical non-compliance”. Model 2 was only ever missing recertification, and Model 3 was any of the above inactive reasons. We performed multivariable modified Poisson regression with robust variance estimator to examine race/ethnicity disparities in the outcome. Models were adjusted for gender and age.

Results:

Of the 44,073 candidates, 6.4% were Black and 16.6% were Hispanic. There were 12,940 (29.4%) candidates that did not recertify MELD labs on schedule and 3,173 candidates (7.2%) that were inactive for any of the specified reasons as listed above. In adjusted analysis Model 1, Black candidates were at 11% higher risk (aRR 1.11, 95%CI 1.05-1.17, p<0.001), and Hispanic candidates were at 24% higher risk (aRR 1.24, 95%CI 1.20-1.28), p<0.001). For Model 2, effect sizes were similar. For Model 3, Black candidates were at 21% higher risk (aRR 1.21, p=0.004) and Hispanic candidates were 12% higher risk (aRR 1.12, p=0.01).

Conclusion:

Black and Hispanic LT candidates are at higher risk of not recertifying their MELD labs or becoming inactive, which may lead to worse waitlist outcomes. Further research and interventions to support waitlist maintenance at the patient and transplant center level are needed for personalized approaches.