Influence of Acuity Circles on Hepatocellular Carcinoma and the Interaction of Gender and Race in Liver Transplantation

The impact of liver transplant allocation policy using acuity circles (ACs) on interactions between race and gender on waitlist mortality or receipt of deceased donor liver transplant (DDLT) is unknown. Using data from the United Network for Organ Sharing (UNOS), we examined adults listed for DDLT from April 3, 2017, to October 4, 2022 (30 months pre- and post-AC). Fine-Gray sub-distribution hazard model explored AC indicators by race and gender interactions and their effect on receipt of DDLT or waitlist mortality. Also explored was AC's impact on hepatocellular carcinoma (HCC) diagnosis and receipt of DDLT or waitlist mortality. 59 592 patients (30 202 pre-AC, 29 390 post-AC) included. For both receipt of DDLT and waitlist mortality, there were no 3-way (AC by race by gender) interactions, indicating that the effects of race and gender on DDLT or waitlist mortality were consistent pre- and post-AC. Irrespective of AC implementation, Black and Hispanic women were less likely to receive DDLT and had an increased risk of waitlist mortality compared to White women. White, Black, and Hispanic men had lower waitlist mortality risk and greater likelihood of receiving DDLT compared to their female race/ethnic counterparts. Patients with HCC had a significantly greater chance for DDLT than non-HCC, although post-AC this effect was attenuated. Patients with HCC were also at greater risk of waitlist mortality pre- and post-AC compared to those without HCC however, the waitlist mortality post-AC was attenuated only for those patients without HCC. To our knowledge, this is the first study to show the interaction of gender and race on waitlist mortality and access to transplantation since the implementation of AC, showing continued disparate outcomes for women both within and across racial groups.