Results of a retrospective cohort study demonstrated few patients with advanced liver disease receive referrals, are wait-listed, or undergo a liver transplant. Most of these deficits occur at the referral step. These findings are based on the results of a study published in JAMA Internal Medicine.

Due to organ scarcity, only a small number of patients with advanced liver disease actually undergo a liver transplant. Disparities may emerge at any stage in the complex process leading up to receiving a liver allograft. Factors such as differences in clinicians’ perceptions of the burden of comorbidity, concerns regarding social and caregiver support, and expectations for adherence to medical treatments may affect referral decisions. These factors have not been assessed in previous studies. Researchers evaluated the rates of and factors associated with referral, wait-listing, and receipt of liver allografts.

The investigators used linked data from comprehensive electronic medical records and the United Network of Organ Sharing. Adult patients with cirrhosis and a Model for End-Stage Liver Disease with addition of sodium score of at least 15 points from October 1, 2011, to December 31, 2017 were enrolled in the study. The study participants were from 129 hospitals in the integrated United States Department of Veterans Affairs (VA) health care system. They were followed until death or December 31, 2018. The investigators performed statistical analyses from April 28, 2020, to January 31, 2021.

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The following factors were examined: sociodemographic (age, insurance, income), clinical (liver disease etiology, severity, comorbidity), and health care facility (complexity, rural or urban, presence of a liver transplant program). The study outcomes were referral, wait-listing, and liver transplantation.

A total of 34,494 patients with cirrhosis were included in the cohort. The mean age was approximately 62 (SD, 7.7) years, 33,560 (97.29%) were men, 22,509 (65.25%) were White, 1534 (4.45%) were referred, 1035 (3.00%) were wait-listed, and 549 (1.59%) underwent a liver transplant within 3 years of meeting clinical criteria for transplantation.

Patients aged 70 years and older were associated with lower rates of referral (hazard ratio [HR], 0.09; 95% CI, 0.06-0.13), wait-listing (HR, 0.07; 95% CI, 0.04-0.12), and transplant (HR, 0.08; 95% CI, 0.04-0.16).

Patients with cirrhosis attributed to alcohol were associated with lowers rate of referral (HR, 0.38; 95% CI, 0.33-0.44), wait-listing (HR, 0.32; 95% CI, 0.27-0.38), and transplant (HR, 0.30; 95% CI, 0.23-0.37).

Comorbidity (none vs >1 comorbidity) was found to be associated with lower rates of referral (HR, 0.47; 95% CI, 0.40-0.56), wait-listing (HR, 0.38; 95% CI, 0.31-0.46), and transplant (HR, 0.28; 95% CI, 0.21-0.38).

Compared with White patients, Black patients were less likely to be referred (HR, 0.82; 95% CI, 0.70-0.95) and wait-listed (HR, 0.73; 95% CI, 0.61-0.88).

Patients with lower annual income and those with VA-only insurance were less likely to meet all 3 outcomes. This association was stronger for wait-listing (HR, 0.67; 95% CI, 0.57-0.79 and HR, 0.41; 95% CI, 0.34-0.50, respectively) and transplantation outcomes (HR, 0.65; 95% CI, 0.53-0.80 and HR, 0.30; 95% CI, 0.22-0.39, respectively).

Compared with patients seen in the Northeast, patients in the West had a significantly lower probability of being referred (HR, 0.70; 95% CI, 0.53-0.93), being waitlisted (HR, 0.48; 95% CI, 0.36-0.64), and undergoing a transplant (HR, 0.50; 95% CI, 0.34-0.74).

Medical records were reviewed for 333 patients who had limited comorbidity but were not referred. Among these patients, organ transplant was considered as a potential option in 176 (52.85%). According to investigators, when documented, medical and psychosocial barriers explained most instances of under-referral.

This study had several limitations. Causal inferences could not be drawn due to the observational study design. Additionally, patients were mostly men with hepatitis C virus or alcohol-related cirrhosis, which may preclude these findings from being generalizable to other populations.

These results showed that few patients with cirrhosis received referrals, were wait-listed, or underwent a liver transplant, with the greatest deficits being found at the referral step. Extending monitoring to the earlier stages of the transplantation process may improve access to organ transplant.

Disclosure: Some study authors declared affiliations with the industry. Please see the original reference for a full list of authors’ disclosures.  


Kanwal F, Hernaez R, Liu Y, et al. Factors associated with access to and receipt of liver transplantation in veterans with end-stage liver disease. JAMA Intern Med. Published online May 24, 2021. doi:10.1001/jamainternmed.2021.2051

This article originally appeared on Gastroenterology Advisor