Disparities in transplant access and outcomes after first cirrhosis decompensation in alcohol-related liver disease.

Background & Aims: Several studies have shown that non-medical factors can determine access to liver transplantation (LT). Most of these studies are from North America, where the healthcare system has specific features that may not be generalisable to Europe. We investigated the factors associated with access to LT in patients admitted for a first episode of decompensated cirrhosis in France and to determine potential treatment gaps according to disease aetiology. Methods: We conducted a retrospective cohort study using the French national health data system to identify patients hospitalised for a first decompensation of cirrhosis between 2015 and 2022, followed until December 2023. We built a frailty model to search for factors associated with access to LT and to quantify inter-centre variability. Then, we compared survival rates and incidence of liver-related death according to disease aetiology, including competing risk analyses. Results: We identified 65,771 patients (73.5% men, 82.3% alcohol-related liver disease [ALD]), with a mean follow-up time of 36 months. Of these patients, 3,596 (5.5%) were transplanted and 35,660 (54.2%) died. Patients with ALD were less likely to be transplanted (hazard ratio [HR] 0.75, 95% CI 0.69-0.81, Conclusions: Our study highlights several factors contributing to unequal access to LT in France. Reduced access for patients with ALD suggests the presence of structural stigma. Impact and implications: This study provides the first national-level evidence from a European country showing that patients with alcohol-related cirrhosis, particularly women and those from socioeconomically disadvantaged backgrounds, experience lower access to liver transplantation and higher liver-related mortality. These findings could be important for clinicians, researchers, and health policymakers seeking to improve equity in transplant access within universal healthcare systems. While our study does not capture all clinical or psychosocial determinants of transplant eligibility, it highlights systemic disparities that could be mitigated through national referral protocols, standardised patient evaluations, and targeted support for vulnerable populations. Future work should integrate clinical data and patient-reported outcomes to further refine these observations and guide practice change.