Abstract

Background: The rising prevalence of alcohol-associated liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD) has led to increases in the need for liver transplantation (LT). The purpose of our study was to investigate disparities in access to LT, and whether those disparities were consistent across etiology of liver disease.

Methods: We performed a retrospective study of 2,391 LT evaluations at a single tertiary transplant center. Multivariable logistic regression analysis adjusting for race and ethnicity, gender, age, evaluation MELD-Na, insurance, Community Health Score, and the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) score was used to assess disparities in overall transplant waitlisting and in being declined for waitlisting due to psychosocial reasons. We also performed interaction analyses to investigate whether these disparities were differential across etiology of liver disease.

Results: The cohort included 2,391 patients evaluated for transplant. In multivariable models the following factors were associated with increased risk of declining for LT waitlist: Medicaid insurance (OR 2.44, 95% CI 1.76-3.37), Medicare insurance (OR 1.71, 95% CI 1.39-2.11), a high-risk SIPAT score (OR 1.77, 95% CI 1.42-2.21), Black race (OR 1.41, 95% CI 1.06-1.87) and older age (OR 1.03, 95% CI 1.02-1.04). The following variables were associated with declining for waitlisting due to psychosocial reasons: ALD (OR 2.43, 95% CI 1.20-4.93), Black race (1.76, 95% CI 1.10-2.82), Medicaid insurance (OR 2.09, 95% CI 1.31-3.31), and a high risk SIPAT score (OR 6.21, 95% CI 4.08-9.45). The risk of being declined for waitlisting due to psychosocial reasons was differentially higher in patients with Medicare insurance with ALD compared to private insurance and in women with ALD. (Figure 1)

Conclusion: Several sociodemographic factors contribute to disparities in transplant access. Among patients with ALD, female patients and patients on public insurance experience even more pronounced barriers to transplant waitlisting. This may reflect a combination of stigma, bias in transplant provider perception, and increased psychosocial barriers in this population. Future directions should include interventions to address bias in the transplant evaluation process and on improving psychosocial resources in higher-risk populations.