Introduction: Racial differences in etiology specific waitlisting indications and outcomes of patients waitlisted for liver transplantation (LT) have been described. However, they have not been explored specifically in patients waitlisted with acute liver failure (ALF), a group with the potential for high waitlist morbidity and mortality.
Methods: Patients waitlisted for LT from 2002-2016 with a primary diagnosis of ALF were investigated using the United Network of Organ Sharing database. Clinical characteristics and causative etiologies were compared between white and black patients with ALF who were waitlisted Status-1 for LT. A competing risk analysis was used to explore racial differences in LT and waitlist removal because of death or becoming too sick between the groups. Log rank testing was used to explore differences in 1-year post transplant survival.
Results: There were 122,124 black and white patients waitlisted for LT during the study period; 5,161 were listed with a primary diagnosis of ALF (7.6% of blacks and 3.8% of whites; p<0.001) (Table 1). Of that ALF cohort, 2,348 patients were waitlisted Status-1 for LT (54.5% of blacks and 43.4% of white; p<0.001). Black patients with ALF who were listed Status-1 had similar MELD scores (36 vs; p=0.06) to white patients. However, black patients had worse coagulopathy (INR 5.4 vs 4.8; p=0.001) and higher bilirubin at presentation (19.5 mg/dl vs 12.2 mg/d; p<0.001) than white patients. Black patients were significantly more likely than white patients to have autoimmune liver disease (18.8% vs 5.3%, p<0.001) and less likely to have drug induced liver injury (40.3% vs 58.7%; p<0.001) as causative etiologies. There was no racial difference in waitlist removal because of becoming too sick or death (HR 1.09; 95% CI 0.89-1.32). However, black patients were significantly more likely to undergo LT (HR 1.19; 95% CI 1.06-1.32) than white patients. Higher rates of LT in black patients was attenuated on multivariable analysis by higher waitlisting bilirubin (HR 1.02; 95% CI 0.91-1.15). One-year post transplant survival was lower in black patients compared to white patients (black 80.3% vs white 85.8%; p=0.03).
Discussion: Black patients are significantly more likely to be waitlisted with ALF, require status-1 listing, and to undergo LT than white patients. Future studies should explore if more acute liver disease at presentation in black patients is due to late referral or inherently worse liver disease.