Racial Disparities in Outcomes After Liver Transplantation

Racial disparities in liver transplant outcomes remain an area of concern despite advancements in organ allocation and post-transplant care. This retrospective cohort study analyzed adult liver transplant recipients from the United Network for Organ Sharing (UNOS) registry between 1988 and 2021 to evaluate differences in graft and patient survival between African American (AA) and Caucasian American (CA) recipients. After excluding non-Black and non-White individuals and pediatric cases, a 3:1 matched cohort was created using propensity-type matching for age, sex, body mass index, and ABO type, resulting in 50,584 patients (13,421 AA and 40,263 CA). Median graft survival was significantly lower in AAs compared to CAs (1,466 vs. 1,787 days, p < 0.0001), as was median patient survival (1,480 vs. 1,815 days, p < 0.0001). Graft failure rates at one year were 2,325/12,708 (18.3%) for AA vs. 5,884/37,762 (15.6%) for CA (Chi² = 50.87, df = 1, V = 0.026, p < 0.0001); at five years, 4,326/10,323 (41.9%) vs. 10,172/30,179 (33.7%), respectively (Chi² = 218.35, V = 0.060, p < 0.0001). Similarly, mortality at five years was 3,516/9,152 (38.4%) for AA vs. 8,232/26,291 (31.3%) for CA (Chi² = 154.41, V = 0.066, p < 0.0001). AAs also had higher Model for End-Stage Liver Disease (MELD) scores at listing and transplant and were more likely to be hospitalized or in the ICU at the time of transplant. Insurance coverage differed significantly, with AAs more likely to have public insurance (6,031/12,739, 47.3% vs. 13,055/36,504, 35.8%, p < 0.0001). These findings suggest that AA liver transplant recipients experience significantly worse outcomes, likely due to a combination of advanced disease at presentation and socioeconomic disparities.