Trauma History Linked to Reduced Access to Liver Transplant in Women

Katherine M. Cooper, MD

Credit: ResearchGate

A new study revealed trauma history is linked to reduced access to a liver transplant for women but not men with chronic liver disease.¹ The study suggests psychiatric symptoms associated with trauma are not the drivers of the gender disparity

Not many studies have assessed the impact of psychological trauma, either mental, emotional, or physical, on liver transplant candidacy and outcomes. There may be several reasons why someone might not be able to get access to a liver transplant: they may be too ill or frail to cope with the surgery, they recently had cancer, a serious infection, a heart attack, or stroke, they may struggle to take the immunosuppressant medicines, and they might experience psychological difficulties afterward.² Therefore, investigators, led by Katherine M. Cooper, MD, from UMass Chan Medical School in Worcester, Massachusetts, conducted a single-center retrospective study on patients who completed a routine liver transplant evaluation between October 2017 and June 2021.¹

The team identified the prevalence of psychological trauma history in liver transplant candidates and assessed the link between trauma history and liver transplant access. The primary outcome measure was a liver transplant listing.

The analysis included 463 patients who completed a liver transplant evaluation. Among the sample, 17% reported a history of trauma: 49 of 149 women and 30 of 304 men. Patients with trauma history were more likely to be younger (P < .001) and White (P = .032), as well as less likely to be living with a family member (P = .002) and to have a stable relationship with a partner (P < .001).

Psychiatric comorbidities, such as depression (P < 0.001), anxiety (P < 0.001), and bipolar disorder (P < 0.001), were more common in patients with a history of trauma. Patients with these comorbidities were more likely to be prescribed a psychotropic medication at the time of the liver transplant evaluation (51% vs 26%; P < .001).

“We did observe higher rates of anxiety and depression in women than men, and previous studies have shown that women are more likely to develop anxious and depressive disorders after a PTE,” investigators wrote. “However, none of the patients in the study were declined for listing or removed from the waitlist for poorly controlled psychiatric comorbidities...These findings suggest that mood and substance use disorders are not the drivers of the gender disparity observed in this study.”

Participants with trauma history were more likely to have a prior diagnosis of acute alcohol-associated hepatitis (P < .001) and a history of substance use with marijuana (P = .028), opioid (P = .002), and cocaine (P < .001).

Trauma history was significantly more common in women (31%) than in men (10%) (P < .001). In fact, patients with a history of sexual trauma were 5.3 times more likely to be a woman (95% confidence interval [CI], 1.1 – 25.6; P = .040). Trauma-related to partner violence was only reported by women.

Moreover, women with a trauma history (80%) were less likely to be listed for a liver transplant than men (93%) (P = .016). A multivariable analysis showed trauma history was independently linked to being declined for a liver transplant in women (odds ratio [OR], 0.2; 95% CI, 0.1 – 0.69; P = .011).

Investigators discovered women with a trauma history were more likely to be removed from the liver transplant waitlist (26% vs 12%; P = 0.045), and this was true even when excluding patients removed for transfer to another center or for medical improvement (22% vs 7%; P = .020). A multivariable analysis revealed trauma history was linked to > 5-fold greater odds of being removed from the liver transplant (OR, 5.8; 95% CI, 1.6 – 20.8; P = .013).

Conversely, men with and without trauma history had similar listings for liver transplants (87% vs 86%; P = .973) and waitlist removals (12% vs 10%; P = .766). Additionally, men with (n = 13) and without (n = 94) trauma history had similar liver transplants, post-liver transplant relapses, rejections, readmissions, and death.

“Currently, assessment of trauma history is not discussed in practice guidance about the psychosocial evaluation and is not included in well-known psychosocial evaluation tools like the SIPAT,” investigators wrote. “These factors in conjunction with the lack of published data on this topic suggest that trauma history may not be routinely queried during the [liver transplant] evaluation process. “

References

1. ^{Cooper KM, Colletta A, Amin D, Herscovici DM, Devuni D. Psychosocial Trauma History Negatively Impacts Liver Transplant Access in Women with Chronic Liver Disease. J Transplant. 2024;2024:2455942. Published 2024 Aug 13. doi:10.1155/2024/2455942}
2. ^{Who is Able to Have a Liver Transplant? NHS Blood and Transplant. https://www.nhsbt.nhs.uk/organ-transplantation/liver/is-a-liver-transplant-right-for-you/who-is-able-to-have-a-liver-transplant/#:~:text=Common%20reasons%20why%20a%20liver,medicines%20after%20a%20liver%20transplant. Accessed August 26, 2024.}