S2880 Racial Disparities in Liver Transplantation Among Patients With Primary Sclerosing Cholangitis

Introduction: Primary sclerosing cholangitis (PSC) is a progressive hepatobiliary disease without effective medical therapies other than liver transplantation (LT). However, disparities in LT access and outcomes for minority patients with PSC remain poorly defined. Methods: We conducted a retrospective cohort analysis using the United Network for Organ Sharing database from 2010-2024. PSC patients listed for LT were stratified by race (non-White vs White). Multivariable competing risks regression was used to investigate the primary outcome of time to waitlist dropout (due to being too sick) or mortality, accounting for LT as a competing risk. Secondary outcomes were time to post-LT graft failure, living donor LT, and listing for cholangiocarcinoma. Results: Among 7,636 PSC patients evaluated, 5733 were White and 1903 were non-White; most non-White patients were Black (62%). Over time, the proportion of non-White patients with PSC listed for LT has risen. Non-White patients had higher MELD scores at listing (20 vs 17, P < 0.001) and were less likely to have concurrent inflammatory bowel disease (61% vs 73%, P < 0.001). Only 28 [1.5%] non-White patients with cholangiocarcinoma were listed for LT compared to 253 [4.4%] White patients (P < 0.001). Donation after circulatory death graft utilization was similar between the 2 groups; however, non-White patients were half as likely to undergo living donor LT (6% vs 12%, RR 0.5, P < 0.001). There was no difference in risk of waitlist dropout/mortality between White and non-White patients on competing risks regression (aHR 1.1, 95% CI 0.8-1.5, P = 0.7), though measures of socioeconomic status like education level (HR 0.8, 95% CI 0.7-0.9, P < 0.001) and public insurance (HR 1.4, 95% CI 1.1-1.7, P < 0.001) were associated with waitlist dropout/mortality. Race, education status, and insurance type were not associated with time to graft failure on Cox regression. Conclusion: Racial disparities persist in access to liver transplantation for PSC, as non-White patients are less likely to receive living donor LT and less likely to be listed with concurrent cholangiocarcinoma. Despite these disparities, clinical outcomes were largely similar, suggesting resilience in care once access is achieved, though measures of socioeconomic status remained associated with waitlist outcomes. Interventions are needed to address barriers to early diagnosis, subspecialty referral, and living donor education in minority communities.