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Table of Contents
LETTER TO EDITOR
Year : 2021  |  Volume : 15  |  Issue : 1  |  Page : 89-90

Gender disparity in liver transplantation in Indian setting


1 Department of Gastroenterology, Arihant Hospital and Research Centre, Indore, Madhya Pradesh; Department of Gastroenterology, Gleneagles Global Health City, Chennai, Tamil Nadu, India
2 Department of Gastroenterology, Gleneagles Global Health City; Department of Hepatology, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
3 Department of Hepatology, Dr. Rela Institute and Medical Centre; Department of Hepatology, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India

Date of Submission16-Jun-2020
Date of Acceptance25-Nov-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. Mayank Jain
Arihant Hospital and Research Centre, Indore - 452 009, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_56_20

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How to cite this article:
Jain M, Sanglodkar U, Venkataraman J. Gender disparity in liver transplantation in Indian setting. Indian J Transplant 2021;15:89-90

How to cite this URL:
Jain M, Sanglodkar U, Venkataraman J. Gender disparity in liver transplantation in Indian setting. Indian J Transplant [serial online] 2021 [cited 2021 Jul 30];15:89-90. Available from: https://www.ijtonline.in/text.asp?2021/15/1/89/312754



Dear Editor,

Liver transplantation (LT) is a life-saving procedure for patients with end stage liver disease. With improvements in surgical techniques and postoperative care, the outcomes of LT have improved considerably. Recent research from the West has shed light on gender disparity that exists in the LT process. Although LT is remarkably altruistic and medically thrilling procedure, there is a huge gender disparity among donors and recipients. The present study was planned to determine the gender imbalance among LT recipients and donors undergoing LT evaluation at our center.

In this retrospective study, we accessed hospital records of patients (Indian and overseas) who underwent LT or were worked up as donors for LT from 2012 to 2017 using hospital information system. Details regarding age, sex, ethnicity and etiology of liver disease were recorded. The data were analyzed using appropriate statistical tests-frequency, proportions, Chi-square test. A P < 0.05 was considered as statistically significant.

A total of 678 patients were registered as recipients for LT at Gleneagles Global Health City, Chennai. Of these, only 26.2% (178) were females-79 pediatric cases (39.7%; total pediatric cases-199) cases, and 99 adult females (20.7%, total adult cases 479). Thus, LT was significantly lower (P < 0.0001) in adult females. Out of 783 donors evaluated for LT, 55% (431) were females. Among the Indian patients, the frequency of female donors was significantly higher at 68% (P < 0.0001). The most common indications for LT in 99 adult female recipients (Indian and overseas) included-nonalcoholic steatohepatitis (26, 26%), viral hepatitis (18, 18%), cryptogenic cirrhosis (16, 16%), autoimmune hepatitis (12, 12%), primary biliary cirrhosis (10, 10%), hepatocellular carcinoma (8, 8%), alcohol (3, 3%), Budd Chiari syndrome, and Wilson's disease (2, 2% each). The most common etiology of LT in males included alcohol and viral hepatitis. The differences in etiology were statistically significant (P = 0.02).

Western data suggest that access to LT is considerably poorer for ethnic minorities, women, and patients of low socioeconomic status or inadequate insurance coverage.[1] The reasons for this are multifactorial-body and organ size considerations, differences in the etiology of liver disease, and limits of the model for end-stage liver disease (MELD) score. MELD score is commonly used the world over for organ allocation in LT. It consists of three parameters-serum creatinine, international normalized ratio, and serum bilirubin. Women have lesser body weight and muscle mass compared to males. Thus, they have lower creatinine levels. This results in underestimation of the degree of renal dysfunction in women. Moreover, their MELD scores are also lower. This puts women folk at a distinct disadvantage of organ allocation. Moreover, hepatocellular carcinoma, the most common standard MELD exception for LT, is more common in males, further increasing the disparity of access to LT.[2],[3]

In an interesting data from liver transplant donors from our center, we noted that of the 783 donors evaluated for living donor LT, 55% were females. Among the Indian patients, the frequency of female donors was higher at 68%. This highlights that females are the preferred and more forthcoming donors for adult as well as pediatric LT in our setting. Over the past decade and a half, India has emerged as a hub for living donor organ transplants in South and Southeast Asia. Interestingly, the majority of living donors in India are women. Data from five centers across India show that for LT, women are 60.5% of the donors, based on figures for 2009–2017.[4] This discrepancy probably stems from the belief that women are givers, societal pressure, males not forthcoming for donation and deep set cultural prejudices. Reassessment of traditional gender roles and a woman's role in her family may help to correct these biases. In our set up, males are the predominant bread winners in the family and hence the family feels that the female should take the risk of mortality (however low it may be) for the sake of the major bread winner. Moreover, lower education status among the females could also be a reason for this discrepancy. Further research into the impact of educational status and financial independence of female donors would provide more insight into this complex problem.

Data from the United States suggest that over a 15-year period, significantly more women than men underwent LT for Wilson disease, primary biliary cirrhosis, drug-induced acute hepatic necrosis, Budd Chiari syndrome, autoimmune cirrhosis, cryptogenic cirrhosis, and nonalcoholic steatohepatitis.[5]

The present study highlights that the LT data are heavily skewed in favor of the male sex. Females are more commonly the donors, more so in Indian patients. Strict vigilance, proper policy making, and greater role by transplant centers to encourage male donors will go a long way in improving the present gloomy scenario.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bryce CL, Angus DC, Arnold RM, Chang CC, Farrell MH, Manzarbeitia C, et al. Sociodemographic differences in early access to liver transplantation services. Am J Transplant 2009;9:2092-101.  Back to cited text no. 1
    
2.
Moylan CA, Brady CW, Johnson JL, Smith AD, Tuttle-Newhall JE, Muir AJ. Disparities in liver transplantation before and after introduction of the MELD score. JAMA 2008;300:2371-8.  Back to cited text no. 2
    
3.
Mathur AK, Schaubel DE, Gong Q, Guidinger MK, Merion RM. Sex-based disparities in liver transplant rates in the United States. Am J Transplant 2011;11:1435-43.  Back to cited text no. 3
    
4.
Chattopadhyay S. Sum of her parts: Why are the vast majority of Indian organ donors women? The Hindu; October 24, 2018.  Back to cited text no. 4
    
5.
Liver Transplantation between 1988 and 2013 in the United States. Available from: http://optn.transplan.hrsa.gov/latestdata/rptdata.asp. [Last accessed on 2020 Feb 19].  Back to cited text no. 5
    




 

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