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Ethnic minorities face higher risk of liver transplant failure

UTSW study of patients with alcohol-associated diseases could lead to interventions that improve outcomes of these procedures

DALLAS – March 12, 2024 – The risk of dying while waiting for a liver transplant or having a transplant fail for patients with alcohol-associated liver diseases is higher among racial and ethnic minorities, according to UT Southwestern Medical Center researchers. The findings, published in Transplantation, could lead to targeted interventions that improve outcomes for high-risk groups suffering from alcohol-associated hepatitis and cirrhosis.

“Our study looked at factors within individual patient populations and uncovered predictors of mortality or graft failure. Our goal is to pinpoint areas toward alleviating disparities in liver transplantation outcomes,” said Thomas Cotter, M.D., Assistant Professor of Internal Medicine and a member of the Division of Digestive and Liver Diseases at UT Southwestern.

Thomas Cotter, M.D.

Thomas Cotter, M.D., Assistant Professor of Internal Medicine, is a member of the Division of Digestive and Liver Diseases at UT Southwestern.

Liver transplants for alcohol-associated liver diseases have increased over the past decade. Alcohol-associated cirrhosis (AAC) now accounts for 32.1% of waitlist cases and 31.5% of transplants. Alcohol-associated hepatitis (AAH) has shown the fastest growth, with a sixfold annual increase on the waitlist and a ninefold increase in transplants.

UTSW researchers examined waitlisted adult patients in the U.S. transplant database from 2015 through 2021, building on their previous research into the link between liver transplant disparities and geographic components. The analysis considered age, sex, race, ethnicity, education level, employment status, and pre-transplant characteristics such as time on the waitlist. Although the database does not include variables for alcohol abstinence prior to transplant, the researchers included controls for periods of abstinence within the context of a large national database. Post-transplant characteristics, including length of hospital stay and comorbidities, also were examined to assess liver transplant frequency, waitlist mortality, and graft survival.

Researchers found variations in waitlist mortalities for AAC, with American Indian/Alaska Native patients facing a 33% higher risk of mortality compared with non-Hispanic whites. Similar trends were observed for Asians (23%) and Hispanics (17%), while non-Hispanic Black patients showed only a 7% higher risk. The study also revealed that Hispanics with diabetes had a higher risk of waitlist mortality and transplant failure. In the AAC group, those of younger age, male sex, with higher body mass index, a job, or a college education tended to show lower rates of mortality across all racial and ethnic minority groups.

AAC patients’ transplant survival outcomes also differed by race and ethnicity. Non-Hispanic Black and American Indian/Alaska Native had the lowest five-year transplant survival rates, whereas Hispanic and Asian patients had similar outcomes compared with non-Hispanic white patients. These disparities emphasized the need for better and group-specific patient care quality, the study authors said.

“This study highlights important demographic, biological, and social determinants of health that can be used for targeted interventions, leading to improved outcomes for racial and ethnic minority populations,” Dr. Cotter said. 

Factors linked to the disparities may include limited transplant access and delayed referral for evaluation, Dr. Cotter said. To address these disparities, he suggested broadening transplant interventions by not only treating mental health and substance abuse, but also considering immunosuppression, psychosocial challenges, and rates of returning to drinking.

The researchers did not observe differences in outcomes for AAH, potentially because of the limited sample size available compared with AAC, the authors said. 

UTSW researchers who contributed to this study from the Department of Internal Medicine are Professors Mack Mitchell, M.D., William Lee, M.D., Jacqueline O’Leary, M.D., and Amit Singal, M.D.; Associate Professors Thomas Kerr, M.D., Ph.D., Arjmand Mufti, M.D., and Lisa VanWagner, M.D.; Assistant Professors Sarah Lieber, M.D., Nicole Rich, M.D., and Jeremy Louissaint, M.D.; postdoctoral researcher Ahmad Anouti, M.D., and resident Mausam Patel, M.D. Contributors from the Department of Surgery are Professors Parsia Vagefi, M.D., Chief of the Division of Surgical Transplantation, and Steven Hanish, M.D., and Assistant Professor Madhukar Patel, M.D.

This research was funded by the National Institutes of Health (U01-AA-026975, R01-MD012565, R01-CA256977, K08-CA259236). Dr. Cotter and the work of his research group are supported by the American Association for the Study of Liver Diseases Clinical, Translational and Outcomes Research Award, and the National Institute on Alcohol Abuse and Alcoholism Career Development Award (K series).