Survival Rates Lower for Black Liver Transplant Recipients Than for White, Hispanic Patients

By Lisa Rapaport

August 27, 2021

(Reuters Health) - Liver transplant survival rates are lower for Black recipients than for white or Hispanic patients, a new U.S. study suggests, although the differences in mortality have shifted over time.

Researchers examined data from the United Network for Organ Sharing (UNOS) registry on 46,997 individuals who received liver transplants between 2002 and 2018. The analysis included 3,898 non-Hispanic Black patients, 36,560 non-Hispanic white patients, and 6,539 Hispanic patients.

Overall, Black liver transplant recipients had significantly higher mortality (adjusted hazard ratio 1.15) compared with white patients, while Hispanic transplant recipients had significantly lower mortality (aHR 0.78) compared with white patients.

Racial disparities in mortality varied during each year of the study, however. Compared to white patients, the absolute difference in age-adjusted mortality peaked at 10.0% greater for Black patients in 2004, when the absolute difference age-adjusted mortality for Hispanic patients was 4.6% lower than for white patients.

Alcohol-associated liver disease explained 13.9% of the mortality disparity between Black and white transplant recipients between 2010 to 2018, the study also found. Another 6.1% of this disparity could be explained by public insurance as opposed to private health benefits.

"Our study suggests that having clinicians and policymakers focus more on alcohol and healthcare access may be a start to help reduce disparities, but given that there are clearly other factors contributing to disparities, it's naive to think this would be enough to bridge the gap," said lead study author Dr. Brian P. Lee, a transplant hepatologist and assistant professor at the Keck School of Medicine at the University of Southern California in Los Angeles.

"Our study should really be a wake-up call that clinicians and policymakers need to re-evaluate how we're delivering care to an increasingly diverse population," Dr. Lee said by email.

The survival gap between Black patients and white patients increased with the number of years post-transplant, the researchers report in the American Journal of Transplantation.

In addition, the study found that Black recipients had a higher severity of liver disease at the time of transplant and tended to die more often from acute or chronic organ rejection than white patients.

Disparities persisted even after the researchers adjusted for a number of demographic and health factors, including where a patient lived, their insurance type, if they had diabetes, and severity of liver disease.

One limitation of the study is that fatalities were identified from Social Security records, and it's possible the cause of death might be incomplete or misclassified in some instances, the study team notes. Race was also self-reported, and categories in the data set didn't enable researchers to distinguish racial categories among Hispanic transplant recipients.

Still, the results underscore the importance of transplant programs making a conscious effort to recognize and address implicit provider biases at time of referral for transplant evaluation and listing for transplant once the evaluation has been completed, said Dr. Nicole Rich, a transplant hepatologist and assistant professor at the University of Texas Southwestern Medical Center in Dallas.

Ensuring equitable access to post-transplant care may also help reduce disparities in outcomes, Dr. Rich, who wasn't involved in the study, said by email.

"Reducing disparities is easier said than done, but culturally tailored programs, use of patient and physician navigators, and increasing education among referring physicians and the community about liver disease and liver transplantation would be a good start," said Dr. Marina Serper, an assistant professor of medicine in the division of gastroenterology and hepatology at the University of Pennsylvania in Philadelphia.

Transplant centers also need to have ways to assess other barriers to care that are not as apparent, Dr. Serper, who wasn't involved in the study, said by email.

"These often have to do with cost, social support, literacy, substance use, and education and could be as simple as helping patients with transportation, synchronizing pharmacy refills, or asking patients if they are having problems with their medications and accessing care," Dr. Serper said.

SOURCE: American Journal of Transplantation, online August 10, 2021.