Abstract
BACKGROUND: Early liver transplant (LT) is associated with favorable outcomes in select patients with severe alcohol associated liver disease (ALD). Sex-based disparities in liver transplant have been recognized, but there are limited data on gender disparities in access to early LT for patients with ALD. METHODS: RESOLVE-ALD is a multicenter cohort of patients with ALD referred for LT evaluation with <6 months of sobriety at 6 US centers between 2018 and 2021. The primary outcome was waitlist enrollment. Secondary outcomes were waitlist removal and receipt of LT. Multivariable logistic regression was used to evaluate the association between gender and listing for LT. Mediation analyses were performed to evaluate mechanisms for disparities in listing. RESULTS: In all, 617 patients were identified, including 376 men (61%) and 241 women (39%). Women had 36% lower odds of listing for LT (95% CI 0.42-0.91) compared with men, adjusting for other predictors of listing. Adjusted for MELD-Na, abstinence period, and serum albumin levels, women had 2.68-times higher odds of waitlist removal ( p <0.01) and 2.04-fold lower odds of receiving an LT ( p =0.01) compared with men. Mood disorders (depression or anxiety) and unemployment status exerted significant indirect effects on the relationship between gender and listing ( p- values <0.05). Gender differences in listing were significantly different, with lower MELD-Na and bilirubin levels and more days abstinent. Two-year post-LT survival was similar in men and women (91.5% vs. 97.4%, p =0.15). CONCLUSIONS: Notable gender disparities in access to LT exist among patients with ALD evaluated with <6 months of sobriety. Lower waitlisting in women is mediated by higher rates of psychiatric conditions and lower rates of employment, though gender-specific alcohol-associated bias may also contribute.