Systematic Sex-Based Inequity in the MELD Score-Based Allocation System for Liver Transplantation in Germany

Transplant International, vol. 38, pp. 13844

Abstract

In liver allocation systems based on the Model for End-stage Liver Disease (MELD) score, sex inequities have been identified in countries with high organ donation rates. Whether similar inequities exist in regions with average to low donation rates remained unclear. We assessed the impact of sex on transplantation rates, waiting list mortality and post-transplant survival in 25,943 patients waitlisted for liver transplantation in Germany between 2003 and 2017 using competing risk analysis. Women are currently underrepresented on the waiting list (33.3%) and among transplant recipients (31.1%) compared to their proportion of severe liver disease cases (35.1%). The introduction of MELD-based allocation has worsened this disadvantage [HR before: 0.89 (0.81-0.98), after: 0.77 (0.74-0.81)]. Three key factors contribute to this disparity: Women have lower creatinine levels despite worse renal function, reducing their MELD score (median 1, 0-3). Second, exceptional MELD points are more frequently granted to men [HR 1.61 (1.54-1.69) compared to regular allocation]. Third, the small height of women has the highest impact on the probability of not being transplanted [adjusted HR 0.85 (0.81-0.9)]. Even in countries with lower organ donation rates, MELD-based allocation leads to sex inequity. Measures are needed to ensure sex-neutral liver allocation in MELD-based systems worldwide.

Authors 13

1. Leke Wiering

   Humboldt-Universität zu Berlin · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin

   Affiliation as printed

   Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité (Junior) Clinician Scientist Program, Berlin, Germany

   Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Charité Campus Mitte, Berlin, Germany

   Charité—Universitätsmedizin Berlin, Germany

2. Annette Aigner

   Humboldt-Universität zu Berlin · Charité - Universitätsmedizin Berlin

   Affiliation as printed

   Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany

   Charité—Universitätsmedizin Berlin, Germany

3. Marieke van Rosmalen Aachen Eurotransplant International Foundation

   Eurotransplant

   Affiliation as printed

   Eurotransplant International Foundation, Leiden, Netherlands

   Eurotransplant International Foundation, Netherlands

4. Brigitta Globke

   Humboldt-Universität zu Berlin · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin

   Affiliation as printed

   Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité (Junior) Clinician Scientist Program, Berlin, Germany

   Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany

   Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Germany

5. Tomasz Dziodzio

   Humboldt-Universität zu Berlin · Charité - Universitätsmedizin Berlin

   Affiliation as printed

   Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany

   Charité—Universitätsmedizin Berlin, Germany

6. Nathanael Raschzok

   Humboldt-Universität zu Berlin · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin

   Affiliation as printed

   Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité (Junior) Clinician Scientist Program, Berlin, Germany

   Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany

   Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Germany

7. Münevver Demir

   Humboldt-Universität zu Berlin · Charité - Universitätsmedizin Berlin

   Affiliation as printed

   Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Charité Campus Mitte, Berlin, Germany

   Charité—Universitätsmedizin Berlin, Germany

8. Wenzel Schöning

   Humboldt-Universität zu Berlin · Charité - Universitätsmedizin Berlin

   Affiliation as printed

   Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany

   Charité—Universitätsmedizin Berlin, Germany

9. Frank Tacke

   Humboldt-Universität zu Berlin · Charité - Universitätsmedizin Berlin

   Affiliation as printed

   Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Charité Campus Mitte, Berlin, Germany

   Charité—Universitätsmedizin Berlin, Germany

10. Petra Reinke

    Humboldt-Universität zu Berlin · Freie Universität Berlin · Charité - Universitätsmedizin Berlin

    Affiliation as printed

    Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin Center for Advanced Therapies (BeCAT), Berlin, Germany

    Charité—Universitätsmedizin Berlin, Germany

11. Johann Pratschke

    Humboldt-Universität zu Berlin · Charité - Universitätsmedizin Berlin

    Affiliation as printed

    Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany

    Charité—Universitätsmedizin Berlin, Germany

12. Robert Öllinger

    Humboldt-Universität zu Berlin · Charité - Universitätsmedizin Berlin

    Affiliation as printed

    Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany

    Charité—Universitätsmedizin Berlin, Germany

13. Paul Viktor Ritschl

    Humboldt-Universität zu Berlin · Berlin Institute of Health at Charité - Universitätsmedizin Berlin · Charité - Universitätsmedizin Berlin

    Affiliation as printed

    Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité (Junior) Clinician Scientist Program, Berlin, Germany

    Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany

    Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Germany