Determinants of racial disparities in outcomes from liver transplantation Open Access

Ross Driscoll, Katherine (Fall 2020)

Permanent URL:


Black patients experience significant and persistent disparities in survival after liver transplant, the only treatment for end-stage liver disease. The association of race, survival, and shorter-term outcomes, such as hospital admission, remains unclear. The overall goal of this project was to identify determinants of racial disparities in hospital admission and survival among liver transplant recipients.

In Aim 1, we used national data from a population-based registry of transplant recipients to determine whether the association of race with post-transplant survival differed by characteristics of the transplant center. While Black patients had lower post-transplant survival than White patients overall, racial disparities varied substantially across transplant centers. We did not find significant effect modification by center volume, proportion of minority patients, quality rating, or geographic region.

In Aim 2, we estimated the association between patient race and risk of hospital readmission within six months of transplant (Aim 2A), and did not find a clinically meaningful difference in hospitalization between Black and White patients. In a mediation analysis, we found that readmission within six months of transplant did not impact the association between race and survival (Aim 2B).

In Aim 3, we used data from the Emory Transplant Center (ETC) to estimate the association between race and aspects of post-transplant hospitalization not collected in national data. We found that disparities in hospital admission rates arose in the late post-transplant period. Black patients were more likely to have rejection as a cause of admission, and were more likely to be admitted emergently than White patients.  

In this dissertation, we identified substantial variation in racial disparities after liver transplantation across transplant centers that was not explained by selected characteristics. While race was not associated with readmission within six months of transplant in a national cohort, preliminary data from the ETC suggests that disparities in hospital admissions may arise beyond six months. Black patients appeared to have different causes of readmission than White patients, and differences in admission urgency may point to opportunities to prevent these admissions. Further research is needed to identify modifiable factors associated with racial disparities in hospital admissions and survival after liver transplant.  

Table of Contents

Chapter 1: Background and Literature Review.. 12

Chronic Liver Disease, End-Stage Liver Disease and Hepatocellular Carcinoma. 12

Epidemiology of CLD and ESLD in Adults. 13

Hepatocellular Carcinoma. 15

Liver Transplantation. 15

Living Donor Liver Transplantation. 15

Deceased Donor Allocation. 16

Indications and Evaluation for Transplant 17

Care of the Liver Transplant Recipient 20

Outcomes of Liver Transplantation. 21

Graft and Overall Survival 21

Unplanned Hospitalization after Transplant 27

Disparities in Outcomes for Black Liver Transplant Recipients. 31

Disparities along the Health Care Trajectory. 32

Potential Determinants of Disparities. 35

Summary of Critical Literature Review.. 42

Chapter 2: Significance and Specific Aims. 43

Study Motivation. 43

Potential Application of the Results to Liver Transplantation. 44

Potential Application of the Results Outside Transplantation. 45

Specific Aims. 45

Chapter 3: Data Sources and Methods. 47

Data Sources. 47

Scientific Registry of Transplant Recipients. 47

Emory Transplant Center 47

Study Population. 47

Specific Aims 1 and 2. 47

Specific Aim 3. 48

Variables. 48

Exposure. 48

Outcomes. 49

Covariates. 50

Analytic Methods. 53

Aim 1. 53

Aim 2A.. 53

Aim 2B.. 54

Aim 3. 54

Chapter 4: Aim 1. 56

Abstract 56

Introduction. 57

Methods. 58

Results. 61

Discussion. 63

Tables and Figures. 68

Chapter 5: Aim 2. 81

Abstract 81

Introduction. 82

Methods. 83

Results. 86

Discussion. 89

Tables and Figures. 94

Chapter 6: Aim 3. 101

Abstract 101

Introduction. 103

Methods. 104

Results. 106

Discussion. 111

Tables and Figures. 115

Chapter 7: Public Health Implications and Future Directions. 127

Summary of Findings. 127

Strengths and Limitations. 129

Future Directions. 130

References. 133

About this Dissertation

Rights statement
  • Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.
  • English
Research Field
Committee Chair / Thesis Advisor
Committee Members
Last modified

Primary PDF

Supplemental Files