Assessing Multi-level Barriers to Racial Equity in Living Liver Donor Transplantation

PROJECT SUMMARY/ABSTRACT
Due to the organ shortage, more than 15,000 patients with end-stage liver disease (ESLD) are waiting for a
life-saving liver transplant (LT) in the US, but fewer than 50% of waitlisted patients will go on to receive a LT.1
As a result, more than 2,000 LT waitlisted patients die each year. Racial disparities compound the organ
shortage: ESLD rates are increasing in the Black population, but Black patients receive disproportionately
fewer LTs than White patients.2 Living donor liver transplantation (LDLT) is a safe and effective treatment that
increases organ availability for LT.3 Yet Black ESLD patients receive fewer than 10% of LDLTs. Efforts to
redress these disparities are urgently needed.
Assessing multilevel factors that affect Black potential LT recipients (LTR) along with potential living liver
donors (LLDs) is essential for developing interventions that foster equity in access to LDLT. In particular,
understanding how social determinants of health (SDOH) mediate racial disparities in access to LDLT is a
critical barrier to equity in access to LDLT because SDOH-related barriers are concentrated in racial minorities.
Few retrospective studies have identified patient-level factors associated with disparities in access to LDLT
(e.g., distance to transplant center, insurance, and neighborhood income). Understanding the mechanisms of
the interaction between potential LLD and LTR experiences during the transplant and donor selection process
is critical to effectively targeting interventions designed to improve access to LDLT to both the donor and
recipient experiences.
The objective of the proposed study is to assess multilevel factors contributing to disparities in
access to the LT waitlist and LDLT for Black patients with ESLD and potential LLDs. In this descriptive
study, we will compare access to LT and LDLT among Black and White patients at two transplant centers with
large Black ESLD patient populations (Nashville, TN, and Durham, North Carolina). We will engage LDLT
stakeholders (i.e., potential LTRs, potential LLDs, and transplant clinicians) to identify multilevel barriers,
facilitators, and strategies for overcoming barriers to LT and LDLT using mixed methods. We will leverage
findings to develop an intervention designed to foster equity in LT and LDLT, and assess its feasibility using
implementation science. The specific aims are to:
1. Assess center documented multi-level factors contributing to racial disparities in LT and LDLT
2. Characterize patient perceived multi-level factors that influence access to LT and LDLT
3. Assess the interaction between multilevel factors contributing to racial disparities in LT and LDLT over time
Study results will inform the development of a culturally sensitive, multilevel, transplant center-based
intervention to increase Black patients’ access to LDLT, and to save lives.