MARYLAND research found that age, race and insurance status were the patient characteristic most strongly linked with receipt of liver transplantation among people with alcohol-related liver disease (ARLD), while county-level social vulnerability and travel distance were not independently associated.
Researchers analysed statewide inpatient records from 2013 to 2020, alongside mortality data, to examine liver transplant access among patients with ARLD. Of 28,053 patients identified with ARLD, 663, or 2.4%, received a liver transplant.
ARLD is the most common indication for liver transplantation in the United States. Around 2 million people are estimated to have alcohol-related cirrhosis, while patients with decompensated ARLD made up 17–28% of the transplant waiting list. In 2017, 27% of deaths on the waiting list occurred among patients with ARLD. The incidence of decompensated ARLD was also projected to almost double by 2040, increasing the importance of understanding barriers to transplantation.
After multivariable adjustment, Black patients had lower odds of receiving a liver transplant than other patients in the analysis (adjusted odds ratio [aOR] 0.43, 95% confidence interval [CI] 0.31–0.58). Medicaid recipients also had lower odds (aOR 0.44, 95% CI 0.35–0.56).
Black patients accounted for 27.9% of the overall ARLD cohort but 12.5% of transplant recipients. Medicaid was the most common payer among patients with ARLD (36.8%), but accounted for 20.8% of those who underwent transplantation.
Age differences were also observed. Compared with patients aged 55–64 years, the odds were lower among those aged 65–74 years (aOR 0.56, 95% CI 0.39–0.79) and those aged 75 years or older (aOR 0.06, 95% CI 0.015–0.25).
County-level social vulnerability index tertile and travel distance to transplant centres were not independently associated with transplantation.
The findings described differences in who ultimately received a transplant but did not establish that race, insurance or other non-clinical factors caused those differences. The dataset did not include disease severity, transplant eligibility, alcohol-use history, frailty, psychosocial support, contraindications, or referral, evaluation and waiting-list activity. As transplantation was the only observable endpoint, the study could not determine whether disparities emerged at referral, evaluation, listing or organ allocation.
The study was also limited by retrospective administrative data, possible coding inaccuracies and its single-state design. Maryland has two liver transplant centres located in the same city and operates under a distinctive all-payer hospital rate-setting system, limiting generalisability to other states.
Future studies linking administrative, registry and transplant referral data could help identify where differences in liver transplant access emerge. The researchers said multi-state and national cohorts are needed to determine whether the Maryland findings extend to other populations.
Reference
Tomasocvic LM et al. Factors influencing access to liver transplantation for alcohol-related liver disease. J Liver Transpl. 2026;DOI:10.1016/j.liver.2026.100378.
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