A Comprehensive Assessment of Liver Transplant Trends and Outcomes Among Adults With Steatotic Liver Disease in the U.S.

Abstract

Background and Aims

Steatotic liver disease (SLD) is the leading indication for liver transplantation (LT) among U.S. adults. We aim to provide comprehensive updates of LT trends and outcomes among adults with SLD, highlighting racial, ethnic, and sociodemographic disparities.

Methods

Using data from the 2010 to 2023 United Network for Organ Sharing registry, we performed a retrospective cohort study evaluating LT waitlist trends, waitlist outcomes, and post-LT survival among 65,675 adults with SLD. Disparities in LT outcomes were evaluated using adjusted competing risks analyses.

Results

From 2014 to 2023, there was an increasing proportion of Hispanics, women, and younger adults with SLD listed for LT. For Hispanics, this was driven by metabolic dysfunction–associated steatohepatitis (MASH); 19.9% of MASH wait-listings in 2023 were Hispanics. For women and younger adults (18–39 years), this was driven by alcohol-associated liver disease (ALD); 30.9% and 16.4% of ALD-related wait-listings in 2023 were women and younger adults, respectively. Women (vs men) had greater waitlist removal risk (subdistribution hazard ratio (sHR) 1.12, 95% confidence interval (CI) 1.07–1.18) and lower likelihood of LT receipt (sHR 0.87, 95% CI, 0.85–0.90). Ethnic minorities had worse outcomes, particularly Hispanics, who had a 37% higher risk of waitlist removal (sHR 1.37, 95% CI, 1.30–1.45) and 16% lower likelihood of LT receipt (sHR 0.86, 95% CI, 0.82–0.87) vs non-Hispanic whites. Disparities in post-LT survival were also observed.

Conclusion

In 2023, nearly one-quarter of MASH liver transplant waitlist registrants were Hispanics. Approximately half and 1 in 6 ALD waitlist registrants were women and younger adults, respectively. These concerning trends are amplified by the disparities in LT outcomes observed among women and ethnic minorities.