Racial and gender disparities in access to living donor liver transplantation between 1999–2021

Background By comparing LDLT with death and LT listing, we evaluated disparities in access to LDLT among different races/ethnicities and genders. Methods Two databases were queried for all patients listed for LT in the US from 1999-2021, and for adults aged 25-64 who died of cirrhosis or hepatocellular carcinoma. The primary outcomes were the LDLT to listing ratio (LDLR), the rate of receiving an LDLT while on the list, and LDLT to death ratio (LDDR), the rate of receiving an LDLT compared to dying of end stage liver disease. Results From 1999 to 2021, 5087 patients received LDLT. Annual LDLT increased from 124 to 361 (p>0.05) with 2 breakpoints: +53 annual percent change (APC) from 1999-2021, -11% 2001-2009, and +8% 2009-2021 (all p<0.01). From 1999-2013, LDLT in women decreased (APC -3.5%), but increased after 2013 (APC 14%), surpassing men in 2021 (all p<0.001). Deaths increased annually from 15,868 to 34,727 (APC 3.3%, p<0.001) with the highest increase in women (APC 4.5%, p<0.001). LT listing barely increased (APC 0.6%, p<0.001). The overall LDDR had similar breakpoints to LDLT. Black patients had significantly lower LDLR compared to other races/ethnicities and lowest LDDR without breakpoints (both p<0.001). Women had less of a LDDR decline compared to men (p<0.001). Conclusion LDLT rates are only starting to return to earlier levels after the decrease between 2001-2009. Black patients remain without significant improvement in low LDLT rates. Despite increased LDLT rates in women, their death rates also increased. LDLT is an underutilized tool to improve transplant access with unaddressed disparities.