Model for End-Stage Liver Disease 3.0: One step forward to mitigate sex and gender disparities in liver transplant

Studies have shown that female liver transplant (LT) candidates are disadvantaged in the grafts allocation system based on the Model for End-stage Liver Disease (MELD) score due to reasons including but not limited to overestimated renal function with creatinine, access to size-matched organs, and implicit bias. 1 Lai J.C. Pomfret E.A. Verna E.C. Implicit bias and the gender inequity in liver transplantation. Am J Transplant. Jun. 2022; 22: 1515-1518https://doi.org/10.1111/ajt.16986 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar To mitigate the sex-based disparity, the United Network for Organ Sharing (UNOS) recently adopted MELD 3.0, which gives additional 1.3 points to female candidates. 2 Kim W.R. Mannalithara A. Heimbach J.K. et al. MELD 3.0: The Model for End-Stage Liver Disease Updated for the Modern Era. Gastroenterology. Dec 2021; 161: 1887-1895.e4https://doi.org/10.1053/j.gastro.2021.08.050 Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar However, there have been concerns regarding how to define female sex in MELD 3.0 for transgender and gender-non-binary (TGNB) people, defined as those whose gender identities are not in line with sex at birth 3 Vélez C. Casimiro I. Pitts R. Streed Jr., C. Paul S. Digestive Health in Sexual and Gender Minority Populations. Am J Gastroenterol. Jun 1 2022; 117: 865-875https://doi.org/10.14309/ajg.0000000000001804 Crossref Scopus (9) Google Scholar . This is especially important for those who receive gender-affirming hormone therapy (GAHT), given the potential impact on serum creatinine. 4 Eckenrode H.E. Flynn J.T. Mohottige D. Advancing kidney health justice through gender-affirming care. Nat Rev Nephrol. Jun. 2022; 18: 343-344https://doi.org/10.1038/s41581-022-00575-y Crossref Scopus (3) Google Scholar In response, UNOS now inquires transplant programs to enter “sex for purposes of adult MELD calculation” in addition to “sex at birth.” For example, if the candidate’s sex at birth was male but currently taking feminizing GAHT, female may be selected as “sex for purposes of adult MELD calculation,” and extra MELD points will apply. This will allow TGNB people on feminizing GAHT to receive extra MELD points, given they might face similar disparity as cisgender women. Additionally, this new data point will help better understand the potential disparity by capturing the number and characteristics of TGNB people waitlisted and received LT.