Socio-Economic Inequalities in End Stage Liver Disease: a Scoping Review of Deprivation Metrics
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King J.J.
Temperley L.
Geneen L.
Wallace D.
Verne J.
Doree C.
Tsochatzis E.
Thorburn, D.
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2025
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Liver disease is a growing public health concern, with most of its risk factors being preventable. As liver transplantation (LT) remains the only cure for end-stage liver disease (ESLD), equitable access is essential. The COVID-19 pandemic highlighted how social determinants of health (SDoH), particularly socio-economic status (SES), affect outcomes in vulnerable populations. Given the multifactorial nature of SES and limited access to individual-level data, composite SDoH scores at population levels have emerged as valuable tools to evaluate the impact of deprivation on healthcare access. This review explores the literature on survival disparities by SES in ESLD patients, before and after LT, using composite SDoH scores. A systematic search of MEDLINE and Embase (inception to 19th February 2025) identified studies examining pre- or post-transplant mortality by socio-economic status (SES), using composite SDoH scores. Eligible studies included adults with ESLD and those awaiting or having received a deceased donor LT, with data sourced from national databases or large centres (<10,000 ESLD patients or <800 awaiting or post-LT patients). The search retrieved 6,095 references and two reviewers independently screened 4,423 individual studies, applying the Critical Appraisal Skills Programme (CASP) checklist for quality assessment. Disagreements were resolved through discussion or by a third reviewer. This review included 23 studies: 8 examined pre-LT survival, 10 post-LT survival, and 5 covered both. All but one study were conducted in the US, with most published after 2020. Across the studies, 11 different composite SDoH indices were used. Quality assessment confirmed adequate sample sizes and valid description of SDoH indices. In the pre-LT phase, all studies showed association between social deprivation with poorer outcomes, with 85% (11/13) finding higher pre-listing and waiting list mortality in the most deprived groups. In the post-LT phase, findings varied by geographic granularity: studies using county-level indices found no significant associations, while those using postcode or census-level data showed that higher post-transplant mortality was more prevalent in those from deprived SES. Deprived SES is associated with higher mortality across all steps of LT journey, but these primarily US-based data limit the applicability of our findings to other countries and healthcare systems. The barriers faced by disadvantaged groups remain unexplored internationally. Composite deprivation scores at the smallest geographic units provide a practical way to assess SES; non- US countries are encouraged to develop and use such scores to examine survival disparities and LT access in ESLD populations (Figure presented).
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Gut