Background Geographic disparity in access to liver transplantation (LT) exists. This study compared demographics, waitlist, and transplant dynamics of multi-listed (ML) versus singly listed (SL) LT candidates.

Methods Data regarding adult, primary (1°), non-status 1, LT candidates (n=59,690) from 1/1/05 to 12/31/11 were extracted from UNOS STAR files and compared by chi-square and Wilcoxon rank sum tests. Candidates with MLs within the same donor service area (DSA), and/or without time overlap between listings were excluded. In cases of >2 listings, the LT center was designated as the 2^nd listing center; whereas for non-transplanted ML candidates it was the true 2^nd listing center. [median (IQR) = med-IQR]

Results: There were 1,491 (2.5%) ML candidates during the 7 year study period; the % of secondary (2°) listings increased nearly 4-fold (1% in 2005; 3.7% in 2011; p<0.001). The most common etiology of liver disease was HCV (36%). ML compared to SL candidates were more often male (70% vs 66%, p=0.001), white (79% vs 71%, p<0.001), blood type O (52% vs 46%, p<0.001), non-diabetic (80% vs 75%, p<0.001), college educated (55% vs 39%, p<0.001), privately insured (75% vs 59%, p<0.001), and without exception points (85% vs 80%, p<0.001). At the 1° listing, ML, compared to SL, candidates had lower MELD scores both at initial listing [med-IQR 14 (11-17) vs 15 (11-21); p<0.001] and at final removal [med-IQR 17 (9-23) vs 22 (15-28), p<0.001]. Second listing occurred at med-IQR of 238 (102-537) days after 1° listing, at a med-IQR MELD score of 16 (12-21).

998 (67%) ML candidates received a LT, 818 (82%) at the 2° listing center. The med-IQR distance traveled between 1° and 2° centers was 474 (146-1028) miles. ML recipients spent a med-IQR of 316 (165-643) vs 53 (18-129) days listed at the 1° and 2° centers, respectively. For ML LT recipients the final med-IQR match MELD was 22 (18-25), compared to 25 (22-26) for SL recipients at the 1° listing DSA (p<0.001).

ML compared to SL recipients, were more likely to receive a DCD liver (6.5% vs 5.2%, p=0.047), but less likely to receive a CDC high risk liver (6.9% vs 8.9%, p=0.03). Med-IQR DRI for ML recipients was 1.39 (1.14-1.69), clinically similar to SL recipients (1.39) (1.13-1.69).

Conclusions: A small and distinctive cohort of LT candidates pursue ML, indicating a willingness and means to travel for LT. Travel expedites LT, since ML candidates undergo LT shortly after 2° listing and at lower MELD scores. The benefit of ML can be negated by equalizing LT access.

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