Addressing gender-based disparities in liver transplantation: A global analysis of surgical access and donor organ allocation

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BACKGROUND: Sex- and gender-based inequities remain a persistent challenge in liver transplantation (LT), influencing referral pathways, waitlist outcomes, donor organ allocation, and post-transplant survival. Differences in body size, model for end-stage liver disease (MELD)-based prioritization, disease etiology, and structural healthcare factors have contributed to disparities in surgical access and organ distribution worldwide. Recent policy modifications, including MELD 3.0 implementation, aim to mitigate longstanding inequities. AIM: To synthesize global evidence from 2000-2026 evaluating gender disparities in LT access, waitlist mortality, donor allocation practices, and surgical outcomes, and to highlight emerging strategies designed to improve equity in transplantation systems. METHODS: A narrative global analysis was conducted using recent registry analysis, multicenter cohort studies, systematic reviews, and policy evaluations published between 2000 and 2026. Key endpoints included listing probability, waitlist duration and mortality, access to deceased and living donor transplantation, allocation algorithms, donor-recipient size matching, and post-transplant outcomes. RESULTS: Across studies, women consistently demonstrated reduced access to transplantation and increased waitlist mortality compared with men. Pooled analyses involving > 377000 candidates reported lower transplant access for women (hazard ratio = 0.88) and increased waitlist mortality risk (hazard ratio = 1.16). Allocation systems incorporating serum creatinine and body-size metrics contributed to lower prioritization scores, with women showing higher adjusted waitlist mortality risk and increased disadvantage associated with estimated liver volume and body surface area. Disease-specific cohorts revealed longer waitlist duration and lower transplant probability among female candidates with hepatocellular carcinoma and metabolic liver disease. Policy reforms such as MELD 3.0 were associated with increased female transplant representation and reduced disparities in transplant opportunity and waitlist mortality, although improvements diminished over time, and body-size differences remained influential. Living donor LT and split-liver strategies emerged as potential mechanisms to mitigate sex-based inequities by addressing donor-recipient size mismatch and expanding organ access. Post-transplant outcomes showed complex patterns, with some data suggesting higher early mortality but improved long-term survival in women compared with men. CONCLUSION: Gender disparities in LT arise from multifactorial interactions among biological differences, allocation algorithms, surgical considerations, and systemic healthcare inequities. Although policy innovation such as MELD 3.0 have improved equity, persistent gaps in surgical access and donor allocation remain globally. Future strategies should include sex-adjusted allocation metrics, expansion of living donor programs, improved referral pathways, and prospective evaluation of equitable transplant policies to ensure fair access and optimal outcomes in LT worldwide. Future strategies should directly target the cause of disparity. Renal function-informed or sex-adjusted scoring to reduce creatinine-related underprioritization, along with size-aware allocation and greater use of split or living-donor transplantation, may improve access for smaller candidates. Reducing procedural variation can be achieved by standardizing, monitoring and reevaluating organ acceptance processes specifically for sex- and gender-associated inequities. The above-mentioned changes should be evaluated in studies that can produce sex- and body size-stratified transplant rates, waiting time, waitlist death or delisting and post-transplant graft and patient outcomes.

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