Increasing Living Liver Donors May Reduce the Existing Disparity in Access to Liver Transplant Among Women

Close of belly of a girl with liver transplant scars.
Investigators aimed to determine whether availability of a living donor could overcome the disparity in access to liver transplant among women.

The existing disparity in access to liver transplant (LT) tissues among the sexes may be bridged by increased access to liver tissues from living donors, according to a retrospective cohort study published in JAMA Surgery.

Data were sourced from the Multi-Organ Transplant Program at the University Health Network in Canada. All patients (N=1289) in need of an LT between 2012 and 2019 were assessed for availability of potential living donors and events which occurred while the patient was on the waiting list.

Candidates were 35.6% women, aged mean 56.1 (SD, 10.0) years, and major etiologies included alcohol liver disease (22%), hepatitis C (22%), and nonalcoholic fatty liver disease (16%).

The average Model for End-stage Liver Disease incorporating sodium levels (MELD-Na) was 20.3 (SD, 8.6) among all patients, 21.2 (SD, 8.3) among women, and 19.8 (SD, 8.7) among men.

At 1 year, 724 patients had undergone LT, 302 were on the waiting list, and 276 had dropped out. At study conclusion, 783 patients had an LT, 90 remained on the waiting list, 122 were delisted due to deterioration, 58 were delisted due to symptom improvement, and 219 had died.

While on the waiting list, 210 patients had a potential living donor LT and 142 a potential deceased donor LT. A total of 309 patients failed to receive LT, 107 of whom had a potential living donor.

Overall survival among women at 1 year was 80.0% and 67.5% at 5 years; survival among men at 1 and 5 years was 81.2% and 68.1% (P =.40), respectively.

Having a potential living donor was associated with decreased risk for death or dropout within the first 6 months of listing for both women (hazard ratio [HR], 0.41; 95% CI, 0.25-0.68; P <.001) and men (HR, 0.60; 95% CI, 0.40-0.91; P =.01). This trend remained significant for women at 15 months (HR, 0.52; 95% CI, 0.34-0.79; P =.002) but not for men (HR, 0.81; 95% CI, 0.59-1.11; P =.19).

Increased MELD-Na scores (³25) were associated with higher and earlier chance of receiving LT among women (HR, 1.82; 95% CI, 1.39-2.39; P <.001) and men (HR, 1.73; 95% CI, 1.39-2.17; P <.001).

Instantaneous LT was more likely among patients who had a potential living donor (HR, 1.54; 95% CI, 1.35-1.76; P <.001). Stratified by sex, men without a potential donor were more likely to undergo instantaneous LT than women (HR, 1.29; 95% CI, 1.04-1.60; P =.01).

This study may have been limited by lack of access to information on the socioeconomic status of patients; it remains unclear whether any advantage or disadvantage based on socioeconomic status may have been a contributing factor to these observed trends.

These data indicated that the disparity of access to LT that exists for women may be effectively addressed by living donors.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Karnam RS, Chen S, Xu W, et al. Sex disparity in liver transplant and access to living donation. JAMA Surg. Published online August 18, 2021. doi:10.1001/jamasurg.2021.3586