Sex and body size disparities under MELD 3.0: Evaluation of persisting gaps in liver transplant access.

backgroundThe July 2023 implementation of MELD3.0 aimed to address longstanding sex disparities in liver transplant access. However, its impact has been understudied.

methodsWe analyzed US transplant registry data (February 4, 2020-September 30, 2024) among adult candidates for liver transplant. Using a difference-in-differences design, we assessed the impact of MELD3.0 during immediate and 3-month postimplementation ("burn-in") periods on receipt of (1) a top 5 organ offer or (2) transplant. Poisson and logistic models estimated the offer and transplant probabilities. Mediation and subgroup analyses by height were also conducted.

resultsWe analyzed 9,952,473 person-day observations from 60,159 candidates for liver transplant. Following MELD3.0, women had greater relative increases in top 5 organ offer rates (rate ratio: 1.14 1.25 1.37 at implementation; rate ratio: 1.11 1.16 1.22 at 3 mo). Pre-MELD3.0, transplant rates were lower for women than men (OR: 0.84 0.86 0.89 ). Post policy, women had greater relative improvements in transplant access than men (OR: 1.16 1.36 1.60 at implementation; OR: 1.09 1.18 1.29 at 3 mo), but this advantage diminished over time, with the model-estimated improvement for women relative to men declining to OR 0.81 by the study end. In mediation analysis, adjustment for height eliminated the difference in transplant rates by sex (OR: 0.98 1.01 1.05 ). Among taller (≥166 cm) candidates, baseline differences by sex persisted (OR: 0.89 0.92 0.96 ), but not in the shorter (<166 cm) group (OR: 0.92 0.97 1.03 ). Post policy, the benefit for women was more pronounced in shorter candidates (OR: 1.19 1.47 1.83 ).

conclusionsMELD3.0 led to early gains in transplant access for women, though this effect diminished over time and differences by sex mediated by body size persisted.