Female gender in the setting of liver transplantation

Abstract

The evolution of liver diseases to end-stage liver disease or to acute hepatic failure, the evaluation process for liver transplantation, the organ allocation decision-making, as well as the post-transplant outcomes are different between female and male genders. Women’s access to liver transplantation is hampered by the use of model for end-stage liver disease (MELD) score, in which creatinine values exert a systematic bias against women due to their lower values even in the presence of variable degrees of renal dysfunction. Furthermore, even when correcting MELD score for gender-appropriate creatinine determination, a quantifiable uneven access to transplant prevails, demonstrating that other factors are also involved. While some of the differences can be explained from the epidemiological point of view, hormonal status plays an important role. Moreover, the pre-menopausal and post-menopausal stages imply profound differences in a woman’s physiology, including not only the passage from the fertile age to the non-fertile stage, but also the loss of estrogens and their potentially protective role in delaying liver fibrosis progression, amongst others. With menopause, the tendency to gain weight may contribute to the development of or worsening of pre-existing metabolic syndrome. As an increasing number of patients are transplanted for non-alcoholic steatohepatitis, and as the average age at transplant increases, clinicians must be prepared for the management of this particular condition, especially in post-menopausal women, who are at particular risk of developing metabolic complications after menopause.

Keywords: Liver transplantation; Female gender; Estrogens; Model for end-stage liver disease score; Creatinine; Gender donor-recipient match

Core tip: Gender differences play an important role in liver diseases, their evolution and outcome, and in liver transplantation, not only in terms of access to this resource, but also in terms of graft survival, metabolic aspects, and quality of life after liver transplantation. Not only gender differences, are important, however, but clearly the different hormonal status throughout a woman’s lifetime determines many aspects not only regarding fertility and sexual issues such as pregnancy, but also metabolic complications. Notwithstanding this, decision-making algorithms regarding indications, risk factors, and outcomes after transplant do not yet incorporate many of these concepts that affect the clinical practice.