Background: Women (W) with cirrhosis awaiting liver transplantation (LT) experience higher rates of waitlist mortality than men (M). We aimed to understand the impact of active “delisting for being too sick” (as opposed to death) on gender disparities in waitlist outcomes.

Methods: Included were non-Status 1 adults (age≥18y) listed for primary LT from 1/1/07-7/1/14 in the UNOS registry. Excluded were those with any exception points or had an unknown etiology for listing. The primary outcome was delisting with the removal codes “too sick” or “medically unsuitable”. Logistic regression evaluated the association between female sex and delisting.

Results: Of 45,366 LT candidates, 17,281(38%) were W. A total of 7,123 (16%) died on the waitlist and 5,194 (11%) patients were delisted for sickness. Both death (16 vs. 15%) and delisting (13 vs. 11%) were more frequent in W vs. M (p<0.01 for both). Compared to delisted M, delisted W differed significantly in age (58 vs. 57y), performance status (70 vs. 60%), %private insurance (47 vs. 53%), and hepatic encephalopathy (HE; 38 vs 34%) [p<0.01 for each], but similar by %ascites (49 vs. 52%), albumin (2.9 vs. 2.9), listing MELD (18 vs. 18), delisting MELD (28 vs. 27), and waitlist time (5.9 vs. 6.3 months) [p>0.05 for each].

In univariable logistic regression, female sex was associated with delisting (OR 1.18, 95%CI 1.14-1.29; p<0.01). The effect of female sex on delisting persisted (OR 1.12, 95%CI 1.03-1.21; p<0.01) even after controlling for the following significant factors: age (OR 1.03), listing MELD (OR 0.99), performance status (OR 0.98), height (OR 0.99), region (OR 1.20), ascites (OR 1.15), HE (OR 2.92), and private insurance (OR 0.83) [p<0.03 for each].

Compared to W who died on the waitlist, W who were delisted for sickness differed by age (58 v. 57), performance status (59 v. 62), %HE (38 v. 29%), %ascites (49 v. 42), listing MELD (18 v. 17), final MELD (28 v. 27), albumin (3.0 v. 2.9) and %AIH/cholestatic disease (19% v. 21%) [p<=0.03 for each].

Conclusions: W are more likely than M to be actively removed from the LT waitlist for sickness, prior to death, despite similar MELD at delisting and adjustment for other known factors associated with waitlist mortality. Our data suggest the need for better tools to capture sickness in W, as well as qualitative investigation into the social, behavioral, and non-liver-related factors that lead to more frequent practices of delisting W from the waitlist.

CITATION INFORMATION: Cullaro G, Lai J. Women Are Delisted for Being Too Sick for Liver Transplant More Frequently Than Men. Am J Transplant. 2017;17 (suppl 3).

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