Published online Feb 28, 2019. doi: 10.3748/wjg.v25.i8.980
Peer-review started: November 12, 2018
First decision: January 6, 2019
Revised: January 13, 2019
Accepted: January 18, 2019
Article in press: January 18, 2019
Published online: February 28, 2019
It is well-established in the literature that women have worse transplant-related outcomes than men, including lower rates of transplant and increased risk of waitlist mortality and dropout. The reasons for these disparities are unclear.
Hospital admissions are common among patients with cirrhosis, and may be a surrogate marker for disease progression that more accurately captures the differences in experience between men and women living with cirrhosis, and may help explain gender disparities in waitlist outcomes.
Thus, we aimed to evaluate the role of gender on risk of hospitalization for patients on the liver transplant waitlist.
Our cohort included adults (≥ 18 years) with cirrhosis listed for liver transplant at University of California - San Francisco (UCSF) from March 2012 to December 2014 who were seen as outpatients and enrolled as a part of a prospective trial. Patients listed for transplant with model for end- stage liver disease (MELD) exception points for hepatocellular carcinoma were excluded, as were patients lost-to-follow up at 12 mo and those with severe hepatic encephalopathy. At the time of study enrollment, patient demographics and baseline laboratory values were collected. Clinical information regarding complications of patients’ liver disease were assessed by enrolling clinician. The primary outcome was any hospitalization within 12 mo from study enrollment, and the secondary outcome was the number of inpatient days within 12 mo. Logistic regression and negative binomial regression evaluated the association of all listed covariates with the primary and secondary outcomes.
A total of 392 patients were enrolled during the study period; 41% were women and 61% were non-Hispanic Caucasian, with median (interquartile ranges) age of 58 years (51-63). During the 12-mo study period, 186 (47%) patients were hospitalized at least once. Of these 186 patients, 89 (48%) were readmitted at least once and 47 (25%) were readmitted more than once. More women than men were hospitalized at least once within the 12-mo study period (54% vs 43%, P = 0.03). In univariable logistic regression, the odds of being hospitalized at least once within 12 mo was 1.6 times higher among women compared to men (P = 0.03). In multivariable analysis, female gender remained significantly associated with hospitalization after adjusting for MELDNa, albumin, ascites, and frailty [adjusted odds ratios (OR) 1.6, 95% confidence interval (CI) 1.1-2.6; P = 0.03]. Female gender was also associated with a higher number of total inpatient days within 12 mo on univariable [incidence rate ratio (IRR) 1.7, 95%CI: 1.1-2.6, P = 0.02) and multivariable analysis (adjusted IRR 1.9, 95%CI: 1.2-3.0, P < 0.01). There was a trend toward women being readmitted more often than men (54% vs 42%), but this did not reach statistical significance (P = 0.11).
Women on the liver transplant waitlist are significantly more likely to be hospitalized than men, and are hospitalized for a higher number of days, even after adjustment for illness severity. Among those who were hospitalized at least once, there was a trend toward higher rates of readmission among women in comparison to men. These findings suggest that the clinical course of cirrhosis among women and men differs despite similarities in traditional measures of severity of illness.
Our findings may help explain the gender disparities in liver transplant waitlist mortality and dropout, by highlighting differences in the experience of living with cirrhosis for women and men. Future studies are needed to evaluate gender-specific interventions in order to truly optimize the management of women and men living with cirrhosis and to eliminate waitlist disparities.