Retrospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 28, 2019; 25(8): 980-988
Published online Feb 28, 2019. doi: 10.3748/wjg.v25.i8.980
Women on the liver transplantation waitlist are at increased risk of hospitalization compared to men
Jessica B Rubin, Marie Sinclair, Robert S Rahimi, Elliot B Tapper, Jennifer C Lai
Jessica B Rubin, Jennifer C Lai, Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA 94143 United States
Marie Sinclair, Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
Marie Sinclair, Department of Medicine, the University of Melbourne, Melbourne 3010, Victoria, Australia
Robert S Rahimi, Division of Hepatology, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75346, United States
Elliot B Tapper, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI 48109, United States
Author contributions: Rubin JB, Sinclair M, Rahimi RS, Tapper EB, and Lai JC participated in research design and writing of the manuscript; Rubin JB, Sinclair M, and Lai JC performed the research; Rubin JB and Lai JC analyzed the data.
Supported by NIA Grants for Early Medical and Surgical Subspecialists’ Transition to Aging Research (R03AG045072, Lai); NIA Paul B. Beeson Career Development Award in Aging (K23AG048337, Lai); and NIDDK National Research Service Award Hepatology Training Grant (T32DK060414, Rubin). These funding agencies played no role in the analysis of the data or preparation of this manuscript.
Institutional review board statement: This study was reviewed and approved by the institutional review board at the University of California - San Francisco.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Jennifer C Lai, MD, MBA, Associate Professor, Department of Medicine, Division of Gastroenterology and Hepatology, University of California - San Francisco, 513 Parnassus Avenue, UCSF Box 0538, San Francisco, CA 94143, United States.
Telephone: +1-4154766422 Fax: +1-4154760659
Received: November 8, 2018
Peer-review started: November 12, 2018
First decision: January 6, 2019
Revised: January 13, 2019
Accepted: January 18, 2019
Article in press: January 18, 2019
Published online: February 28, 2019
Research background

It is well-established in the literature that women have worse transplant-related outcomes than men, including lower rates of transplant and increased risk of waitlist mortality and dropout. The reasons for these disparities are unclear.

Research motivation

Hospital admissions are common among patients with cirrhosis, and may be a surrogate marker for disease progression that more accurately captures the differences in experience between men and women living with cirrhosis, and may help explain gender disparities in waitlist outcomes.

Research objectives

Thus, we aimed to evaluate the role of gender on risk of hospitalization for patients on the liver transplant waitlist.

Research methods

Our cohort included adults (≥ 18 years) with cirrhosis listed for liver transplant at University of California - San Francisco (UCSF) from March 2012 to December 2014 who were seen as outpatients and enrolled as a part of a prospective trial. Patients listed for transplant with model for end- stage liver disease (MELD) exception points for hepatocellular carcinoma were excluded, as were patients lost-to-follow up at 12 mo and those with severe hepatic encephalopathy. At the time of study enrollment, patient demographics and baseline laboratory values were collected. Clinical information regarding complications of patients’ liver disease were assessed by enrolling clinician. The primary outcome was any hospitalization within 12 mo from study enrollment, and the secondary outcome was the number of inpatient days within 12 mo. Logistic regression and negative binomial regression evaluated the association of all listed covariates with the primary and secondary outcomes.

Research results

A total of 392 patients were enrolled during the study period; 41% were women and 61% were non-Hispanic Caucasian, with median (interquartile ranges) age of 58 years (51-63). During the 12-mo study period, 186 (47%) patients were hospitalized at least once. Of these 186 patients, 89 (48%) were readmitted at least once and 47 (25%) were readmitted more than once. More women than men were hospitalized at least once within the 12-mo study period (54% vs 43%, P = 0.03). In univariable logistic regression, the odds of being hospitalized at least once within 12 mo was 1.6 times higher among women compared to men (P = 0.03). In multivariable analysis, female gender remained significantly associated with hospitalization after adjusting for MELDNa, albumin, ascites, and frailty [adjusted odds ratios (OR) 1.6, 95% confidence interval (CI) 1.1-2.6; P = 0.03]. Female gender was also associated with a higher number of total inpatient days within 12 mo on univariable [incidence rate ratio (IRR) 1.7, 95%CI: 1.1-2.6, P = 0.02) and multivariable analysis (adjusted IRR 1.9, 95%CI: 1.2-3.0, P < 0.01). There was a trend toward women being readmitted more often than men (54% vs 42%), but this did not reach statistical significance (P = 0.11).

Research conclusions

Women on the liver transplant waitlist are significantly more likely to be hospitalized than men, and are hospitalized for a higher number of days, even after adjustment for illness severity. Among those who were hospitalized at least once, there was a trend toward higher rates of readmission among women in comparison to men. These findings suggest that the clinical course of cirrhosis among women and men differs despite similarities in traditional measures of severity of illness.

Research perspectives

Our findings may help explain the gender disparities in liver transplant waitlist mortality and dropout, by highlighting differences in the experience of living with cirrhosis for women and men. Future studies are needed to evaluate gender-specific interventions in order to truly optimize the management of women and men living with cirrhosis and to eliminate waitlist disparities.