![]() ![]() Electronic health records (EHRs) store longitudinal information on the health and clinical care of individuals, including diagnoses, procedures, medications, and laboratory test results. However, the UNOS database does not allow for investigation of sex differences at the population level. The majority of previous studies investigating sex differences in liver transplant utilized data from the United Network for Organ Sharing (UNOS) database, which allows for analysis of demographics, cause of liver disease, MELD scores at listing, comorbidities, and outcomes. The lack of explanation from previous studies suggests no single factor can fully explain the sex difference in liver transplant, but rather a constellation of differences exist between males and females, leading to the observed disparity. Indeed, males tend to be listed with higher creatinine, estimated glomerular filtration rate (eGFR), and MELD scores than females 3, 4, 16– 18, but replacement of creatinine with eGFR did not improve the MELD model in females 3, 11, 18. Several studies postulated that decreased body size in females leads to lower creatinine levels which in turn disadvantages females in MELD scoring 3, 16, 17. Likewise, controlling for geographic disparities did not ameliorate the sex disparity in receiving a liver transplant 12. After controlling for estimated liver size 12, 14 or height 15, sex disparities in transplant were reduced, but not eliminated. Previous studies attempted to explain the sex disparity in liver transplants by investigating factors such as size mismatches between donor-recipient pairs, geographic disparities, and lower creatinine levels in females. Females spend longer on the waitlist 8, 9, are more likely to die or become too sick for transplantation while on the waitlist 3, 8, 10– 12, and are less likely to receive MELD exception points than males 13. Sex differences in liver transplant are well documented. Notably, sex disparities in liver transplant have widened in the MELD era 7, 8, however, no modifications to MELD based on sex have been accepted. These effects on MELD’s prediction led to several proposed modifications to MELD scoring 2, including the sodium-adjusted MELD score 5, 6 (MELDNa) which has replaced the original MELD in clinical practice. Additionally, other factors can affect MELD’s mortality prediction 2, including hyponatremia, nutritional status, and sex 3, 4. ![]() Individuals with these diagnoses receive exception points to increase their listing MELD scores and decrease their time to transplant. In some cases, MELD does not adequately capture the severity of illness, such as hepatocellular carcinoma, hepatopulmonary syndrome, and portopulmonary hypertension 2. The MELD allocation system is based on the “sickest first” principle whereby individuals with the highest scores have priority access to organs. MELD scores were initially calculated from three laboratory values, creatinine, international normalized ratio of prothrombin rate (INR), and bilirubin 1. In 2002, the Organ Procurement and Transplantation Network (OPTN) adopted the model for end-stage liver disease (MELD) scoring system to allocate livers based on objective medical criteria. ![]()
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