Comparative waitlist mortality of autoimmune liver disease: A systematic review and meta-analysis

BACKGROUND & AIMS: Autoimmune liver diseases (AILDs) such as autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC) show differing waitlist outcomes. This meta-analysis aimed to synthesize comparative waitlist mortality across AILD subtypes and non-autoimmune etiologies, such as metabolic-associated steatotic liver disease (MASLD) or alcohol-associated liver disease (ALD). METHODS: Following PRISMA guidelines, MEDLINE, PubMed, Embase, Scopus, and Cochrane CENTRAL were searched from inception to October 2025. Eligible studies included adults listed for liver transplantation with comparative data for waitlist mortality according to etiology. Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled using random-effects meta-analyses. RESULTS: Twelve studies were included. PBC had a higher waitlist mortality risk than ALD (HR: 1.43; 95% CI: 1.19-1.71), PSC (HR: 1.38; 95% CI: 1.17-1.64), and AIH (HR: 1.11; 95% CI: 1.02-1.21). PSC showed lower waitlist mortality risk when broadly compared with non-PSC etiologies (HR: 0.72; 95% CI: 0.66-0.79). However, when comparing based on specific etiologies, no significant differences were observed for PSC versus ALD (HR: 0.95; 95% CI: 0.68-1.32), PSC versus AIH (HR: 0.92; 95% CI: 0.84-1.02), or AIH versus MASLD (HR: 0.91; 95% CI: 0.81-1.03). Between-study heterogeneity ranged from minimal to substantial across comparisons. CONCLUSIONS: PBC is consistently associated with higher waitlist mortality risk compared with PSC, AIH, and ALD, highlighting potential under-prioritization of this condition for liver transplant. Allocation policies may consider disease-specific exceptions or prognostic models tailored to AILDs to reduce waitlist mortality disparities.