S2379 Gender Disparities in Liver Transplantation: A Systematic Review and Meta-Analysis of Access, Waitlist Outcomes, and Post-Transplant Survival

Introduction: Gender disparities in liver transplantation have emerged as a critical equity issue, with growing evidence suggesting systematic disadvantages for women throughout the transplant process. While individual studies have reported gender differences in waitlist mortality, transplant access, and post-transplant outcomes, comprehensive quantitative synthesis of this evidence remains lacking. Understanding the magnitude and consistency of these disparities is essential for informing policy reforms and clinical practice improvements. Methods: We systematically searched PubMed, Cochrane, and Google Scholar databases (2005–2024) for studies reporting gender-stratified outcomes in adult liver transplant candidates or recipients. This review was registered with PROSPERO (CRD420251039195). We included original peer-reviewed studies reporting adjusted effect estimates for transplant rate, waitlist mortality, or post-transplant outcomes. Pooled hazard ratios (HRs) were calculated using random-effects models where appropriate. Results: Eleven studies encompassing 377,789 participants were included. Waitlist mortality (5 studies) showed a significantly increased risk for women (pooled HR 1.16, 95% confidence interval [CI]: 1.11–1.20; P < 0.001; I² = 48%). The effect was particularly pronounced for frail men versus non-frail women (HR 3.4; P = 0.03), but became non-significant after adjusting for height (HR 1.05, 95% CI: 0.98–1.12). Transplantation access (3 studies) revealed reduced access for women (pooled HR 0.88, 95% CI: 0.86–0.90; P < 0.001), with substantial heterogeneity (I² = 94%) reflecting variation in access pathways. Women had decreased odds of receiving deceased donor transplantation (HR 0.86, 95% CI: 0.84–0.88) and over twice the risk of not accessing living donor transplantation when MELD-Na <20 (HR 2.04, 95% CI: 1.31–3.14). Post-transplant outcomes demonstrated time-dependent effects: women experienced 5% longer hospital stays (adjusted IRR 1.05, 95% CI: 1.02–1.08), a 22% higher short-term mortality risk (HR 1.22, 95% CI: 1.03–1.44), but a 6% lower long-term mortality risk (HR 0.94, 95% CI: 0.89–0.99). Conclusion: Across the liver transplant continuum, women face significant and consistent disadvantages, including elevated waitlist mortality and reduced access to transplantation. Although post-transplant outcomes vary over time, the overall findings highlight the need for gender-sensitive policies and clinical decision-making to reduce disparities in liver transplantation.