A 2002 landmark study published in The Lancet reported that Black recipients of liver transplants had lower post-transplant survival rates than white or Hispanic patients. Since then, there have been dozens of interventions, including a new system to prioritize organ allocation based on an objective score of medical urgency and federal and state legislation to address socioeconomic barriers in solid organ transplantation.
As a hepatologist and liver transplant specialist, my colleagues and I at Keck Medicine of USC hoped that due to these interventions, the survival gap between white and Black recipients of livers would have improved over the last 20 years.
To find out, we analyzed data from the United Network for Organ Sharing registry, which tracks all organ transplants in the U.S. We studied the post-transplant life expectancy of approximately 47,000 Black, Hispanic, and white liver transplant recipients between 2002 and 2018, the last year for which adequate survival data was available.
When we got the results, we were surprised to learn that not only had the outcomes of Black liver recipients not improved, they worsened.
While the survival gap initially narrowed between 2002-2009, it was unchanged in 2010-2013, and then worsened from 2013-2018.
In fact, during the entire study period of 2002-2018, Black patients had, on average, a 15% higher relative chance of dying after a liver transplant than white patients — a disadvantage that was not present among Hispanics. And from 2017-2018, Black patients had a 60% higher relative chance of dying after a liver transplant than white recipients of liver transplants. These results held steady even after statistically adjusting for differences in demographics and medical factors, such as age, sex, geography, diabetes, kidney disease, and others. The survival gap between Black and white patients increased with the number of years post-transplant.
These findings, which we recently published in the American Journal of Transplantation, are concerning given that such disparity worsened after steps were taken to address the issue. It’s also concerning in light of the fact that other areas of transplantation, such as kidney transplantation, have shown that these interventions have led to better survival rates for Black patients.
As part of the study, we investigated why Black liver transplant recipients were still faring so poorly, and we found two main factors.
The first was alcohol-associated liver disease — liver damage as the result of alcohol consumption before the transplant.
We discovered that the proportion of alcohol-associated liver disease among Black liver-transplant recipients almost doubled from 2002-2005 to 2014-2018, outpacing a 36% relative increase in the disease among white liver-transplant recipients.
In addition, Black liver-transplant recipients with alcohol-associated liver disease had a lower survival rate than white liver-transplant recipients with alcohol-associated liver disease.
We also found that Blacks were more likely to have non-private insurance (Medicaid) compared to whites, and that patients with non-private insurance had higher mortality when compared to patients with private insurance.
These two findings emphasize the need for additional research to fully understand the dynamics creating this disparity. Our study showed that transplant rates for alcohol-associated liver disease in the Black community have surged in recent years, which mirrors findings from other research citing the rise in high-risk drinking and alcohol use disorder among Black adults in the general population. The question is, why? Is there a differential lack of access or differential response to alcohol treatment programs? Could differences in social support to maintain sobriety be a factor? Issues like these are key to explore.
Research is also needed to determine if and how health insurance type affects delivery of care. Insurance type is a marker of socioeconomic conditions that affect health outcomes. In addition, the healthcare community must examine if racism or implicit bias play a role in uneven outcomes between patient groups.
We hope our study will be an impetus for change. Traditionally, policymakers and clinicians have focused on biological factors, such as severity of liver disease and co-existing medical conditions, as the drivers of healthcare disparities. Our study suggests that more focus on alcohol use and healthcare access could help to better understand and address the survival gap in liver transplant recipients.
We also need to develop more effective interventions to support Black patients who are candidates for, or receive, liver transplants. We know from non-transplant studies that patients who are underinsured or have a history of substance use are vulnerable populations, and that interventions targeted to mitigate these issues have improved health outcomes. We need to determine how interventions such as community-based enhanced treatment access and culturally sensitive personalized medicine could be applied to liver transplant patients.
There are no quick fixes to bridge the survival gap between white and Black liver recipients. Our study, however, will hopefully encourage innovation on how to best deliver care to eliminate this disparity.
Brian P. Lee, MD, MAS, is a hepatologist and liver transplant specialist with Keck Medicine of USC.