Disparities in liver transplantation for metabolic dysfunction-associated steatohepatitis-associated hepatocellular carcinoma

Table 1 Demographics and clinical characteristics of patients waitlisted for liver transplantation for non-alcoholic steatohepatitis-associated hepatocellular carcinoma, n (%)

	Non-Hispanic White (n = 2713)	Non-Hispanic Black (n = 41)	Hispanic (n = 891)	Asian (n = 115)	Other (n = 50)	Overall P value
Age, median (IQR) (years)	64.0 (59.0, 68.0)	62.0 (56.0, 68.0)	63.0 (59.0, 67.0)	65.0 (60.0, 68.0)	63.0 (58.0, 67.0)	0.002
Male sex	1945 (71.7)	20 (48.8)	465 (52.2)	65 (56.5)	30 (60.0)	< 0.001
Body mass index, median (IQR) (kg/m2)	32.6 (29.0, 36.6)	32.6 (28.7, 37.7)	31.6 (28.1, 35.2)	27.5 (25.0, 30.5)	34.8 (29.4, 37.7)	< 0.001
Days on wait list, median (IQR)	217 (100, 355)	190 (59, 317)	265 (140, 424)	311 (195, 496)	206.5 (102, 360)	< 0.001
History of diabetes at listing	1845 (68.1)	20 (48.8)	603 (68.1)	81 (70.4)	32 (64.0)	0.11
Encephalopathy at listing	1339 (49.4)	15 (36.6)	422 (47.4)	37 (32.2)	26 (52.0)	0.003
Ascites at listing	1666 (61.4)	24 (58.5)	511 (57.4)	53 (46.1)	26 (52.0)	0.004
Laboratory model for end-stage liver disease at listing, median (IQR)	12.0 (9.0, 17.0)	13.0 (8.0, 18.0)	12.0 (9.0, 17.0)	10.0 (8.0, 15.0)	13.0 (9.0, 20.0)	0.01
Albumin at listing, median (IQR)	3.3 (2.9, 3.7)	3.1 (2.5, 3.8)	3.2 (2.8, 3.6)	3.3 (2.9, 3.8)	3.2 (2.6, 3.6)	< 0.001
Creatinine at listing, median (IQR) (mg/dL)	0.9 (0.8, 1.2)	1.0 (0.8, 1.2)	0.8 (0.7, 1.1)	0.8 (0.7, 1.1)	1.0 (0.8, 1.4)	< 0.001
Bilirubin at listing, median (IQR) (mg/dL)	1.6 (1.0, 2.7)	1.8 (0.7, 4.3)	1.6 (1.0, 2.8)	1.5 (0.8, 2.1)	1.6 (1.1, 3.6)	0.17
Received hepatocellular carcinoma exception points	2034 (75.0)	28 (68.3)	703 (78.9)	91 (79.1)	37 (74.0)	0.10
Functional status at listing						< 0.001
Unknown	68 (2.5)	0 (0.0)	6 (0.7)	0 (0.0)	0 (0.0)
10	3 (0.1)	0 (0.0)	3 (0.3)	0 (0.0)	0 (0.0)
20	36 (1.3)	1 (2.4)	20 (2.2)	3 (2.6)	1 (2.0)
30	57 (2.1)	2 (4.9)	30 (3.4)	0 (0.0)	3 (6.0)
40	195 (7.2)	0 (0.0)	34 (3.8)	4 (3.5)	4 (8.0)
50	299 (11.0)	10 (24.4)	85 (9.5)	8 (7.0)	6 (12.0)
60	398 (14.7)	7 (17.1)	149 (16.7)	17 (14.8)	7 (14.0)
70	626 (23.1)	7 (17.1)	231 (25.9)	26 (22.6)	6 (12.0)
80	615 (22.7)	8 (19.5)	198 (22.2)	26 (22.6)	11 (22.0)
90	338 (12.5)	5 (12.2)	106 (11.9)	23 (20.0)	8 (16.0)
100	78 (2.9)	1 (2.4)	29 (3.3)	8 (7.0)	4 (8.0)
Working for income at registration	774 (28.8)	12 (29.3)	195 (22.1)	38 (33.0)	20 (40.0)	< 0.001
Listing era						0.24
Pre-MMAT era (1/1/2015-5/31/2019)	1653 (60.9)	27 (65.9)	517 (58.0)	75 (65.2)	26 (52.0)
Post-MMAT era (6/1/2019-12/31/2021)	1060 (39.1)	14 (34.1)	374 (42.0)	40 (34.8)	24 (48.0)
Candidate final status						0.01
Died	132 (4.9)	2 (4.9)	66 (7.4)	6 (5.2)	4 (8.0)
Transplanted	2127 (78.4)	31 (75.6)	638 (71.6)	93 (80.9)	37 (74.0)
Other	454 (16.7)	8 (19.5)	187 (21.0)	16 (13.9)	9 (18.0)

IQR: Interquartile range; MMAT: Median model for end-stage liver disease era at transplant.

Table 2 Candidate characteristics at listing associated with the likelihood of undergoing liver transplantation for hepatocellular carcinoma in the background of non-alcoholic steatohepatitis, per Cox regression analysis

	Univariable		Multivariable
	HR (95%CI)	P value	HR (95%CI)	P value
Age (years)	1.00 (0.99, 1.00)	0.12	1.00 (1.00, 1.01)	0.18
Male sex	1.17 (1.08, 1.26)	< 0.001	1.16 (1.04, 1.29)	0.01
Race/ethnicity
White	(Reference)		(Reference)
Black	1.07 (0.75, 1.52)	0.71	0.78 (0.54, 1.11)	0.17
Hispanic	0.75 (0.69, 0.82)	< 0.001	0.85 (0.77, 0.95)	0.003
Asian	0.67 (0.54, 0.83)	< 0.001	0.79 (0.63, 0.98)	0.04
Other	0.93 (0.67, 1.28)	0.65	0.98 (0.70, 1.36)	0.89
Height (cm)	1.01 (1.006, 1.01)	< 0.001	1.00 (1.00, 1.00)	0.99
Body mass index (kg/m2)	1.00 (0.99, 1.00)	0.15	--	--
History of diabetes	0.86 (0.80, 0.93)	< 0.001	0.97 (0.89, 1.05)	0.41
Encephalopathy	1.31 (1.22, 1.41)	< 0.001	0.91 (0.83, 0.99)	0.03
Ascites	1.36 (1.26, 1.46)	< 0.001	1.02 (0.93, 1.12)	0.69
Laboratory model for end-stage liver disease score	1.08 (1.08, 1.09)	< 0.001	1.12 (1.11, 1.14)	< 0.001
Albumin (g/dL)	0.82 (0.77, 0.87)	< 0.001	1.03 (0.96, 1.10)	0.45
Serum creatinine (mg/dL)	1.13 (1.07, 1.18)	< 0.001	0.87 (0.81, 0.95)	0.001
Serum bilirubin (mg/dL)	1.14 (1.13, 1.15)	< 0.001	1.03 (1.01, 1.04)	0.001
Receiving hepatocellular carcinoma exception points	0.40 (0.37, 0.43)	< 0.001	0.39 (0.34, 0.44)	< 0.001
Functional status
Unknown	1.40 (1.00, 1.95)	0.049	0.84 (0.59, 1.18)	0.31
10	18.76 (7.59, 46.38)	< 0.001	1.67 (0.40, 7.07)	0.48
20	6.12 (4.35, 8.60)	< 0.001	1.66 (1.13, 2.43)	0.01
30	4.28 (3.17, 5.78)	< 0.001	1.31 (0.95, 1.82)	0.10
40	1.80 (1.40, 2.31)	< 0.001	1.07 (0.82, 1.39)	0.64
50	1.58 (1.25, 1.99)	< 0.001	1.09 (0.85, 1.40)	0.48
60	1.33 (1.06, 1.67)	0.01	1.01 (0.79, 1.28)	0.96
70	1.33 (1.06, 1.65)	0.01	1.08 (0.86, 1.35)	0.53
80	1.08 (0.87, 1.35)	0.49	0.96 (0.76, 1.20)	0.70
90	1.05 (0.83, 1.32)	0.71	0.91 (0.72, 1.15)	0.45
100	(Reference)		(Reference)
On mechanical ventilation	16.54 (7.39, 37.04)	< 0.001	1.25 (0.34, 4.61)	0.74
International normalized ratio	1.31 (1.28, 1.35)	< 0.001	0.96 (0.89, 1.04)	0.32
Working for income	0.97 (0.90, 1.05)	0.51	--	--
United Network for Organ Sharing region
1	(Reference)		(Reference)
2	1.75 (1.42, 2.16)	< 0.001	1.74 (1.42, 2.15)	< 0.001
3	2.62 (2.15, 3.20)	< 0.001	2.57 (2.10, 3.15)	< 0.001
4	1.53 (1.25, 1.89)	< 0.001	1.55 (1.25, 1.92)	< 0.001
5	1.32 (1.08, 1.60)	0.01	1.37 (1.11, 1.68)	0.003
6	1.82 (1.35, 2.46)	< 0.001	1.95 (1.44, 2.65)	< 0.001
7	1.73 (1.39, 2.14)	< 0.001	1.72 (1.39, 2.14)	< 0.001
8	2.01 (1.58, 2.54)	< 0.001	1.74 (1.37, 2.22)	< 0.001
9	1.25 (0.99, 1.59)	0.06	1.25 (0.98, 1.59)	0.07
10	2.54 (2.05, 3.15)	< 0.001	2.44 (1.96, 3.04)	< 0.001
11	2.41 (1.96, 2.97)	< 0.001	2.20 (1.78, 2.72)	< 0.001
Listing era
Pre-MMAT era (1/1/2015-5/31/2019)	(Reference)		(Reference)
Post-MMAT era (6/1/2019-12/31/2021)	1.32 (1.22, 1.42)	< 0.001	1.26 (1.16, 1.36)	< 0.001
			C-statistic = 0.70

HR: Hazard ratio; MMAT: Median model for end-stage liver disease era at transplant.