Disparities in Liver Transplantation Access, Outcomes Persist in the United States

Doctor getting ready for surgery in OR
A study was conducted to assess racial, gender, and socioeconomic disparities related to liver transplantation, including referral, waitlisting practices, allocation, and post-transplant care.

Results from a systematic literature review published in Liver Transplantation outline racial, gender, and socioeconomic disparities in the liver transplantation (LT) care cascade in the United States. Across 28 studies of LT allocation and outcomes, racial and ethnic minorities were found to have lower rates of LT referral and were less likely to undergo living donor LT (LDLT) compared with their White counterparts. Women had lower LT rates after waitlisting compared with men. Additionally, patients without commercial insurance and low-income patients were less likely to undergo LT and had poorer post-LT survival. 

Investigators extracted data from 28 studies: 9 on access to LT evaluation; 13 on LT allocation; and 6 on post-transplantation outcomes. All studies were conducted in the United States. Across all 9 studies assessing LT evaluation access, Black patients were significantly less likely to undergo evaluation and waitlisting for LT compared with White patients. Additionally, 4 studies noted that Hispanic patients had less access to LT evaluation than their White counterparts. Black and Hispanic patients tended to have more advanced liver disease at initial presentation and were less likely to undergo LDLT than White patients. Women and patients without commercial health insurance were less likely to receive LT consultation than men and patients with private insurance, respectively.

Many of the 13 studies assessing LT allocation highlighted gender-based disparities. Overall, women were less likely to undergo LT and were more likely to die while on the waitlist compared with men. The disparity in LT receipt between men and women ranged from 4.6% to 13.9%, depending on study region. To explain this difference, the investigators hypothesized that the Model for End Stage Liver Disease (MELD) — a metric used to rank waitlisted patients by disease severity — is less accurate in predicting outcomes in women. Increased waitlist mortality was also observed among patients with public insurance. In particular, patients on Medicare and Medicaid were 19% and 24% less likely to undergo LT than their counterparts with private health insurance, respectively.

Racial and socioeconomic disparities persisted in post-transplant survival. In several studies, Black patients had substantially lower 2-year post-transplant survival compared with White patients and were also more likely to develop complications within 2 years. Other factors associated with decreased post-transplant survival were low healthcare literacy, having an annual income less than $50,000, and reporting skipping medications due to cost. In 1 study, 34% of Black transplant recipients reported not being able to afford 1 or more post-LT medication compared with just 11% of White patients.

Per these data, the investigators advocated for community-based research to address the structural inequities influencing LT outcomes. Additionally, wider surveillance of patients with end-stage liver disease is necessary to develop better-quality data on existing disparities.

“In conclusion, racial, socioeconomic, and gender-based disparities exist in LT access, waitlist, and post-transplant outcomes,” the investigators wrote. “Data-driven and patient-oriented approaches are needed to reduce disparities in LT in vulnerable populations.”

Disclosure: One study author declared affiliations with the pharmaceutical industry.

Please see the original reference for a full list of authors’ disclosures.


Nephew LD, Serper M. Racial, gender, and socioeconomic disparities in liver transplantation. Liver Transpl. Published online January 25, 2021. doi:10.1002/lt.25996