Sarcopenia and gender disparities in liver transplant waiting lists: evaluating predictive scores and delisting risks

The model for end-stage liver disease (MELD) and model for end-stage liver disease-sodium (MELD-Na) scores are the most widely used for prioritizing patients on the liver transplant (LT) waiting list. However, the quality and accuracy of these scores are questionable. Among the most significant limitations we found the disparity in access to transplantation by gender, with excess mortality demonstrated among women on the waiting list. There is also a lack of consideration for sarcopenic status, which negatively impacts those patients. The gender equity model for liver allocation (GEMA) score has recently been shown to be more discriminating, reducing mortality in women. However, this score still does not consider sarcopenic status. The main objectives of this study were to compare the different scores in order to highlight the one with the best discriminatory performance and to demonstrate the disparity in patients' discharge from the list according to their sarcopenic status.

In order to identify patients registered on the LT waiting list between January 1, 2012 and December 31, 2022, at Rennes University Hospital, we contacted the French Biomedicine Agency, which is responsible for prospectively recording registrations. Data about the body composition and complications prior to liver transplantation were collected retrospectively.

Of the 1,488 patients on the waiting list, 900 cirrhotic patients were included in the analysis. The majority of patients on the list were men (n=746, 82.9%), with a median age of 61 (interquartile range, 55-65) years and a median MELD score of 16 [10-22]. In our study, the predictive score of 3-month delisting with the highest discriminatory power was the gender equity model for liver allocation-sodium (GEMA-Na) score, with a C-index of 0.7205. Of the 59 (6.6%) patients discharged at 3 months, 19 (32%) were women (P=0.002). Regarding body composition, sarcopenia was found in 36% of patients (n=326), mostly men (n=293, 89.9%). The Cox model showed an interaction between sarcopenia and gender on list exit (P=0.03). Sarcopenia was present in 60% (n=24) of men leaving the list, whereas it was in only 11% (n=2) of women leaving the list at 3 months (P=0.001).

In our study, the GEMA-Na score was the most predictive of list deletion. However, this score does not consider sarcopenic status, which is relatively prejudicial to men. Considering sarcopenic status in men therefore seems essential in prioritizing patients on the waiting list, to avoid overlooking new disparities between men and women.