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The “Exported” Liver Transplant Candidate: A Reflection of Geographic Inequity in Liver Allocation
*Rachel Kohn, *Johannes R. Kratz, James F. Markmann, *Parsia A Vagefi
Massachusetts General Hospital/Harvard Medical School, Boston, MA, MA

Objective: Assess the “exported” liver transplant (LT) candidates - those who travel to secondary centers seeking LT.
Design: Single center retrospective study from 1/1/05 to 1/1/13.
Setting: Tertiary care center within UNOS Region 1.
Patients: Adult recipients who were listed at our center, but subsequently achieved LT at a secondary center (LT-exported; n=46) were compared to those recipients who achieved LT at our center (LT-primary; n=283).
Interventions: N/A
Main Outcome Measures: Demographics, LT characteristics, and patient survival comparisons between LT-exported and LT-primary groups.
Results: LT-exported recipients most frequently traveled to UNOS Region 3 (67%), with a mean (SD) distance traveled of 1114 (+/-399) miles. LT-exported patients, when compared to LT-primary recipients, spent more time on the waitlist (879.2 +/- 919.3 vs 350.7 +/- 533.2 days; p<0.00001), were more likely to have cholestatic liver disease (23.9% vs 7.1%, p=0.0003) and private insurance (80.4% vs 52.3%, p=0.0004), but less likely to have alcoholic liver disease (2.2% vs 18.4%, p=0.006) and MELD exception points (6.5% vs 50.2%, p<0.00001). These factors remained significant on multivariate analysis. The odds of exportation to achieve LT significantly increased as waitlist time increased (OR 40.5 {CI 4.43-369.8}, p=0.001 for wait time >24 months). Despite achieving transplant, LT-exported recipients had inferior patient survival (1 year 82% versus 90%; 5 year 66% versus 81%; p=0.04).
Conclusions: A small and distinctive cohort of LT candidates pursue “exportation” to achieve LT. Travel patterns reflect the ongoing geographic disparities in liver allocation, and underscore the need for alterations in liver allocation.

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