ImportanceWomen on the liver transplant waiting list are less likely to undergo a transplant than men. Recent approaches to resolving this disparity have involved adjustments to Model for End-Stage Liver Disease (MELD) scoring, but this will not affect candidates who rely on exception scores rather than calculated MELD score, the majority of whom have hepatocellular carcinoma (HCC).ObjectiveTo evaluate the association between female sex, candidate size, and access to liver transplant among wait-listed patients with HCC.Design, Setting, and ParticipantsThis retrospective cohort study used US transplant registry data of all adult (aged ≥18 years) wait-listed liver transplant candidates receiving an HCC exception score between January 1, 2010, and March 2, 2023.ExposureWait-listed liver transplant candidate sex.Main Outcomes and MeasuresThe association of female sex with (1) deceased-donor liver transplant (DDLT) and (2) death or waiting list removal for health deterioration were estimated using multivariable competing-risks regression. Results with and without adjustment for candidate height and weight (mediators of the sex disparity) were compared.ResultsThe cohort included 31 725 candidates with HCC (mean [SD] age at receipt of exception, 61.2 [7.1] years; 76.3% men). Compared with men, women had a lower 1-year cumulative incidence of DDLT (50.8% vs 54.0%; P < .001) and a higher 1-year cumulative incidence of death or delisting for health deterioration (16.2% vs 15.0%; P = .002). After adjustment, without accounting for size, women had a lower incidence of DDLT (subdistribution hazard ratio [SHR], 0.92; 95% CI, 0.89-0.95) and higher incidence of death or delisting (SHR, 1.06; 95% CI, 1.00-1.13) compared with men. When adjusting for candidate height and weight, there was no association of female sex with incidence of DDLT or death or delisting. However, at a height cutoff of 166 cm, short women compared with short men were still less likely to undergo a transplant (SHR, 0.93; 95% CI, 0.88-0.99).Conclusions and RelevanceIn this study, women with HCC were less likely to receive a DDLT and more likely to die while wait-listed than men with HCC; these differences were largely (but not entirely) explained by sex-based differences in candidate size. For candidates listed with exception scores, additional changes to allocation policy are needed to resolve the sex disparity, including solutions to improve access to size-matched donor livers for smaller candidates.

中文翻译：

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肝细胞癌患者肝移植可及性的性别和大小差异


重要性肝脏移植等待名单上的女性接受移植的可能性低于男性。解决这一差异的最新方法包括调整终末期肝病模型 （MELD） 评分，但这不会影响依赖异常评分而不是计算的 MELD 评分的候选人，其中大多数患有肝细胞癌 （HCC）。目的评估女性性别、候选体型和肝移植可及性在等待名单上的患者之间的关联 HCC.Design、环境和参与者本回顾性队列研究使用了 2010 年 1 月 1 日至 2023 年 3 月 2 日期间接受 HCC 异常评分的所有成人（≥18 岁）等待名单肝移植候选者的美国移植登记数据。主要结局和测量使用多变量竞争风险回归估计女性与 （1） 已故供体肝移植 （DDLT） 和 （2） 因健康恶化而死亡或等待名单删除的相关性。比较了调整和不调整候选人身高和体重 （性别差异的中介） 的结果。结果该队列包括 31 725 名 HCC 候选人 （接受例外的平均 [SD] 年龄，61.2 [7.1] 岁;76.3% 为男性）。与男性相比，女性 DDLT 的 1 年累积发生率较低 （50.8% vs 54.0%;P < .001） 和更高的 1 年累积死亡或因健康恶化而被除名的发生率（16.2% 对 15.0%;P = .002）。调整后，在不考虑大小的情况下，与男性相比，女性的 DDLT 发生率较低 （亚分布风险比 [SHR]，0.92;95% CI，0.89-0.95）和较高的死亡或除名发生率 （SHR，1.06;95% CI，1.00-1.13）。 在调整候选人的身高和体重时，女性性别与 DDLT 或死亡或除名的发生率没有关联。然而，在身高临界值为 166 cm 时，与矮个子男性相比，矮个子女性接受移植的可能性仍然较小 （SHR，0.93;95% CI，0.88-0.99）。结论和相关性在这项研究中，与 HCC 男性相比，患有 HCC 的女性接受 DDLT 的可能性较小，并且在等待名单上死亡的可能性更大;这些差异在很大程度上（但不完全）是由候选人体型的性别差异来解释的。对于列出的具有异常分数的候选人，需要对分配政策进行额外更改以解决性别差异，包括改善较小候选人获得大小匹配的供体肝脏的解决方案。