Author information

¹Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore.

²Division of Gastroenterology and Hepatology, University of Arizona College of Medicine, Phoenix, AZ.

³MBBS Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.

⁴Department of Surgery, National University Hospital, Singapore, Singapore.

⁵Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume City, Fukuoka, Japan.

⁶Liver Center, Saga University Hospital, Saga, Japan.

⁷Houston Liver Institute, Houston, TX.

⁸Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA.

⁹Division of Gastroenterology, Massachusetts General Hospital, Boston, MA.

¹⁰Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA.

¹¹National University Centre for Organ Transplantation, National University Health System, Singapore.

Abstract

Background: The cause of liver disease is changing, but its impact on liver transplantation (LT) for hepatocellular carcinoma (HCC) in women and men is unclear. We performed a nationwide study to assess the prevalence and posttransplant survival outcomes of the various causes of liver disease in women and men with HCC.

Methods: Data were obtained from the United Network for Organ Sharing database from 2000 to 2022. Data related to the listing, transplant, waitlist mortality, and posttransplant mortality for HCC were extracted. The proportion of HCC related to the various causes of liver disease among LT candidates and recipients and posttransplant survival were compared between women and men.

Results: A total of 51 721 individuals (39 465 men, 12 256 women) with HCC were included. From 2000 to 2022, nonalcoholic steatohepatitis (NASH) was the fastest-growing cause of liver disease among female LT candidates with HCC (P < 0.01), followed by alcohol-associated liver disease. NASH overtook chronic hepatitis C as the leading cause of liver disease in 2020 and 2022 among waitlisted women and men with HCC, respectively. Female patients with HCC spent a significantly longer time on the LT waitlist compared with male patients (β: 8.73; 95% confidence interval [CI], 2.91-14.54). Female patients with HCC from alcohol-associated liver disease also have a lower probability of receiving LT (subdistribution hazard ratio: 0.90; 95% CI, 0.82-0.99). Among transplant recipients with NASH HCC, female sex was associated with lower posttransplant mortality compared with male sex (hazard ratio: 0.79; 95% CI, 0.70-0.89; P < 0.01).

Conclusions: Women have a significantly longer waitlist duration compared with men. NASH is now the leading cause of liver disease among both female and male LT candidates and recipients with HCC.