Author information

¹Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, USA. Electronic address: jasmohan.bajaj@vcuhealth.org.

²Department of Hepatology, Institute for Liver and Biliary Sciences, New Delhi, India.

³Division of Transplant Surgery, Virginia Commonwealth University Medical Center, Richmond, USA.

⁴Division of Gastroenterology & Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.

⁵Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong.

⁶Department of Hepatology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.

⁷Gastroenterology and Hepatology Unit, St Paul's Hospital, Millennium Medical College, Addis Ababa, Ethiopia.

⁸Hepatology, Division of Health Sciences, Deanery of Clinical Sciences, University of Edinburgh, Edinburgh, UK.

⁹Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey.

¹⁰Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.

¹¹Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.

¹²Storr Liver Centre, Westmead Millennium Institute, Westmead Hospital and University of Sydney.

¹³Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.

Abstract

Decompensated cirrhosis and hepatocellular cancer (HCC) are major risk factors for mortality worldwide. Liver transplantation, both live-donor (LDLT) or deceased-donor (DDLT) are lifesaving but there are several barriers towards equitable access. These barriers are exacerbated in the setting of critical illness or acute-on-chronic liver failure (ACLF). Rates of LT vary widely worldwide but are lowest in lower-income countries due to lack of resources, infrastructure, late disease presentation, and limited donor awareness. A recent experience by the CLEARED consortium defined these barriers towards LT as critical towards determining overall survival in hospitalized cirrhosis patients. A major focus should be on appropriate, affordable, and early cirrhosis and HCC care to prevent the need for LT. LDLT is predominant across Asian countries, while DDLT is more common in Western countries; both approaches have unique challenges that add to the access disparities. There are many challenges towards equitable access but uniform definitions of ACLF, improving transplant expertise, enhancing availability of resources, and encouraging knowledge between centers, and preventing disease progression are critical to reduce LT disparities.