Retrospective Cohort Study
Copyright ©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Sep 18, 2025; 15(3): 101997
Published online Sep 18, 2025. doi: 10.5500/wjt.v15.i3.101997
Disparities in liver transplantation for metabolic dysfunction-associated steatohepatitis-associated hepatocellular carcinoma
David W Victor, Sudha Kodali, Mazen Noureddin, Elizabeth W Brombosz, Analisa Lopez, Tamneet Basra, Edward A Graviss, Duc T Nguyen, Ashish Saharia, Ashton A Connor, Maen Abdelrahim, Yee Lee Cheah, Caroline J Simon, Mark J Hobeika, Constance M Mobley, R Mark Ghobrial
David W Victor, Sudha Kodali, Tamneet Basra, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Department of Medicine, Houston Methodist Hospital, Houston, TX 77030, United States
Mazen Noureddin, Department of Medicine, Houston Methodist Hospital, Houston, TX 77030, United States
Mazen Noureddin, Houston Research Institute, Houston, TX 77079, United States
Elizabeth W Brombosz, Department of Surgery, Houston Methodist Hospital, Houston, TX 77030, United States
Analisa Lopez, JC Walter Jr Transplant Center, Houston Methodist Hospital, Houston, TX 77030, United States
Edward A Graviss, Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas 77030, United States
Duc T Nguyen, Department of Pediatrics, Baylor College of Medicine, Houston, 77030, United States
Ashish Saharia, Ashton A Connor, Yee Lee Cheah, Caroline J Simon, Mark J Hobeika, Constance M Mobley, JC Walter Jr Transplant Center, Department of Surgery, Houston Methodist Hospital, Houston, TX 77030, United States
Maen Abdelrahim, Neal Cancer Center, Houston Methodist Hospital, Houston, TX 77030, United States
R Mark Ghobrial, J C Walter Jr Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Department of Surgery, Houston Methodist Hospital, Houston, TX 77030, United States
Author contributions: Victor DW and Brombosz EW were responsible for preparation of the manuscript; Victor DW, Brombosz EW, and Ghobrial RM were responsible for conception or design of the work; Victor DW, Graviss EA, and Nguyen DT were responsible for acquisition and analysis of data; Victor DW, Kodali S, Noureddin M, Brombosz EW, Lopez A, Basra T, Graviss EA, Nguyen DT, Saharia A, Connor AA, Abdelrahim M, Cheah YL, Simon CJ, Hobeika MJ, Mobley CM, and Ghobrial RM were responsible for interpretation of data and review of the manuscript; all of the authors read and approved the final version of the manuscript to be published.
Institutional review board statement: This work was conducted under Houston Methodist Institutional Review Board protocol Pro00000587.
Informed consent statement: A publicly available dataset with deidentified data was used for this work; work was conducted under a waiver of consent from the Houston Methodist Institutional Review Board.
Conflict-of-interest statement: The authors have no conflicts to declare in relation to this work.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Data sharing statement: The data are publicly available from the US Scientific Registry of Transplant Recipients.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: David W Victor, MD, Director, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Department of Medicine, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX 77030, United States. dwvictor@houstonmethodist.org
Received: October 4, 2024
Revised: February 12, 2025
Accepted: February 21, 2025
Published online: September 18, 2025
Processing time: 195 Days and 20.2 Hours
Abstract
BACKGROUND

Metabolic dysfunction-associated steatohepatitis (MASH) is increasingly common, as is hepatocellular carcinoma (HCC) in the background of MASH. Liver transplantation (LT) provides superior long-term survival for patients with unresectable MASH-HCC, but not all patients have equal access to transplant. MASH-HCC disproportionately affects Hispanic patients, but minorities are less likely to undergo LT for HCC. Additionally, females also undergo LT at lower rates than males.

AIM

To investigate whether race/ethnicity and sex affect LT waitlist outcomes.

METHODS

Records of adults with MASH-HCC in the United States Organ Procurement and Transplantation Network database listed for LT between 1/2015 and 12/2021 were analyzed.

RESULTS

Most of the 3810 patients waitlisted for LT for MASH-HCC were non-Hispanic (NH) white (71.2%) or Hispanic (23.4%), with only 49 (1.1%) NH Black candidates. Hispanics underwent LT at lower rates than NH whites (71.6% vs 78.4%, P < 0.001), but race/ethnicity did not affect waitlist mortality (P = 0.06). Patients with Hispanic [hazard ratio (HR) = 0.85, 95%CI: 0.77-0.95, P = 0.002] or Asian (HR = 0.79, 95%CI: 0.63-0.98, P = 0.04) race/ethnicity were less likely to undergo LT. Women were also less likely to receive LT (male: HR = 1.16, 95%CI: 1.04-1.29, P = 0.01). Patients in regions 1 and 9 were less likely to be transplanted as well (P = 0.07).

CONCLUSION

Hispanic patients are less likely to undergo LT for MASH-HCC, concerning given their susceptibility to MASH and HCC. There were very few NH Black candidates. Disparities were also unequal across regions, which is particularly concerning in states where at-risk populations have rising cancer incidence. Additional research is needed to identify strategies for mitigating these differences in access to LT for MASH-HCC.

Keywords: Steatotic liver disease; Liver neoplasms; Ethnic and racial minorities; Healthcare disparities; Minority health

Core Tip: Ethnicity, sex, and geographic region affect access to liver transplantation for hepatocellular carcinoma in the background of metabolic dysfunction-associated steatohepatitis, highlighting the need for strategies to address these discrepancies.