The migrated liver transplantation candidate: Insight into geographic disparities in liver distribution

Background A minority of liver transplantation (LT) candidates pursue listing at multiple centers to achieve transplantation. The purpose of this study was to assess the characteristics and outcomes of the migrated LT candidates, that is, those who travel to secondary centers seeking LT. Study Design Single-center retrospective study from January 1, 2005 to January 1, 2013 at a tertiary care center within United Network for Organ Sharing Region 1. Adult recipients who were listed at the primary center of interest, but subsequently achieved transplantation at a secondary center (Massachusetts General Hospital [MGH]-migrated; n = 44) were compared with recipients who achieved LT at the primary center (MGH-transplanted; n = 279). Results The MGH-migrated recipients most frequently traveled to United Network for Organ Sharing Region 3 (70.5%), with a mean (±SD) distance traveled of 1,134 (±392) miles. The MGH-migrated patients, when compared with MGH-transplanted recipients, spent more time on the waitlist (907.6 ± 930.1 days vs 354.9 ± 533.2 days; p < 0.00001), were more likely to have cholestatic liver disease (22.7% vs 6.8%; p = 0.0006) and private insurance (80.0% vs 51.6%; p = 0.0005), but were less likely to have alcoholic liver disease (2.3% vs 18.6%; p = 0.006) and Model for End-Stage Liver Disease exception points (6.8% vs 50.9%; p < 0.00001). On multivariable analysis, candidates with private insurance who lacked both alcoholic liver disease and Model for End-Stage Liver Disease exception point listing were significantly associated with the odds of pursuing migration. Despite achieving LT, MGH-migrated patients had inferior 5-year patient survival rates (63% vs 80%; p = 0.03). Conclusions A small and distinctive cohort of LT recipients pursue migration to achieve transplantation. Travel patterns of migrated LT recipients appear to reflect the ongoing geographic disparities in liver distribution and underscore the need for alterations in policy to allow for equitable distribution.