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Black patients and women have reduced access to liver transplantation for alcohol-associated liver disease.

BACKGROUND AND AIMS
While gender and racial disparities for liver transplantation (LT) are known, it is unclear if disparities exist for patients with alcohol-associated liver disease (ALD). We aimed to compare gender and racial/ethnic differences in mortality, LT listing, and LT rates in patients with and without ALD.


METHODS
We analyzed patients who were listed for LT and/or died of end-stage liver disease (ESLD) between 2014-2018, using the UNOS and Center for Disease Control Wide-ranging OnLine Data for Epidemiologic Research (CDC WONDER) databases, respectively. Patients with ALD were compared to non-ALD patients. Our primary outcome was the ratio of listings for LT to deaths from ESLD - listing to death ratio (LDR)- a previously derived metric to assess access to the waitlist. Chi-squared and multivariable linear regression analyzed differences between gender and race/ethnicity.


RESULTS
There were 65,588 deaths and 16,133 listings for ALD compared to 75,020 deaths and 40,194 listings for non-ALD. LDR was lower for ALD (0.25 vs. 0.54, p<0.001). Black patients had the lowest LDR in both ALD and non-ALD (0.13 and 0.39 for Black patients vs. 0.26 and 0.54 for White patients, p<0.001). Women with ALD had a lower LDR (0.21 vs. 0.26, p<0.001), while women without ALD had higher LDR than men (0.69 vs. 0.47, p<0.001). There were significant negative interactions between women and ALD in LDR and transplant-to-death ratio. Multivariable analysis and a sensitivity analysis, with more liberal definitions of ALD and non-ALD, confirmed these findings.


CONCLUSIONS
Patients with ALD have lower access to LT. Among those with ALD, female and Black patients have the lowest access. New initiatives are needed to eliminate these inequities.