Racial disparities in liver transplantation for hepatitis B: To be or not to be

Several studies have documented significant racial disparities in access to and outcomes of liver transplantation in the United States. A study of United Network for Organ Sharing (UNOS) data from 1994 to 1998 by Reid et al. found underrepresentation of African Americans, 18 to 70 years old, on the liver recipient wait list relative to their proportion in the general US population as well as their higher age-adjusted mortality from cirrhosis. In addition, African Americans patients had more severe liver disease when they were placed on the wait list, were more likely to be removed from the list because of death or becoming too ill, and were less likely to undergo transplantation within 4 years of being placed on the wait list. African Americans patients had a shorter waiting time for orthotopic liver transplantation (OLT), which was consistent with more severe and advanced liver disease at listing. These results suggested that African Americans face barriers to referral for liver transplantation that are likely to include decreased access to care related to higher poverty rates and lower rates of private health insurance in comparison with Caucasians or whites. However, racial disparities in health status and health care quality persist for many disorders after adjustments for education level, household income, and health payer status. Disparities in post–liver transplantation outcomes have also been documented in Asian patients. Nguyen and Thuluvath found lower 2-year graft and patient survival rates after transplantation in Asian and African American patients with respect to Caucasians between 1988 and 1996 that differed by liver disease etiology. African Americans with hepatitis C virus (HCV), cryptogenic cirrhosis, and acute liver failure had worse outcomes than whites; in contrast, Asians with hepatitis B virus (HBV), primary biliary cirrhosis, acute liver failure, and cryptogenic cirrhosis had lower survival rates than whites. A better understanding of the sources of disparities in access and outcomes of liver transplantation is necessary for the development of effective strategies to eliminate them and improve the health status of patients with end stage liver disease residents. A recent report by Moylan et al. showed that some disparities between African Americans and Caucasians in outcomes on the liver transplantation wait list before 2002 can be attributed to UNOS organ allocation policy. The authors compared the outcomes in African Americans and white patients who were placed on the liver transplantation list before (1996-2000) and after (2002-2006) implementation of the Model for End-Stage Liver Disease (MELD) liver donor allocation policy. Moylan et al. confirmed the disparities reported by Reid et al. among patients placed on the wait list in the prior MELD era (1996-2000). In contrast, the odds of dying or becoming too sick for liver transplantation and the odds of receiving liver transplantation within 3 years under MELD did not differ by race. The MELD allocation policy also corrected a disparity between Asian-Pacific Islanders and Caucasians in the probability of receiving liver transplantation for primary hepatocellular carcinoma (HCC). Yet, racial disparities in liver transplantation persist. African Americans with cirrhosis who were transplanted between 2002 and 2006 had a higher median MELD score, which indicates ongoing barriers to referral for liver transplantation in the MELD era. African Americans transplanted between 2002 and 2006 also continued to experience lower graft and patient