Measuring health inequalities in liver transplantation: a systematic review of deprivation scores for survival in end-stage liver disease.

Objective: Composite deprivation scores have proven useful to evaluate the impact of social determinants on healthcare access, yet the lack of a standardised approach limits their widespread utility. As liver transplantation (LT) remains the only curative treatment for end-stage liver disease (ESLD), we systematically reviewed whether lower socioeconomic status (SES), measured using composite deprivation indices, is associated with increased mortality before or after transplantation. Design: Systematic review without meta-analysis. Data sources: MEDLINE and Embase were searched from database inception to 19 February 2025, with reference-list screening of key papers. Eligibility criteria: Observational studies reporting ESLD-related mortality by deprivation groups (defined with SES deprivation indices), candidates referred or registered for deceased-donor LT, or LT recipients. Eligible studies were required to use national registries or equivalently large datasets. Data extraction and synthesis: Two reviewers independently screened studies and extracted data. Risk of bias was assessed using an expanded Critical Appraisal Skills Programme framework. Results were synthesised narratively following Synthesis Without Meta-analysis reporting guidance. Results: 23 studies were included: 9 examined pre-LT survival, 9 post-LT survival and 5 covered both. All but one study were conducted in the United States of America (USA/US), with most published after 2020. 14 different composite indices were used. 79% (11/14) of pre-LT studies found higher prelisting or waitlist mortality in the most deprived groups. Post-LT studies using broad area indices found no significant associations, while those using smaller area data showed that higher post-transplant mortality was more prevalent in more deprived SES. Conclusions: This systematic review suggests that socioeconomic deprivation is associated with higher pretransplant mortality, with post-transplant effects varying by the spatial resolution of the deprivation index used. Incorporating composite indices at the smallest spatial scale into transplant evaluation and non-US health-systems planning may help identify universal inequities and inform targeted public health interventions.