Liver transplantation remains one of the most effective treatments for patients with end-stage liver disease (ESLD). Research shows that advances in liver transplantation have led to increased 1-year patient survival rates (ranging from 84.5 percent to 94.1 percent). However, access to advanced therapies is not determined by medical need alone.
A new cohort study published in JAMA Network Open suggests that where an ESLD patient lives — and where they receive transplant care — may influence their likelihood of receiving a living donor liver transplant (LDLT). The findings highlight how neighborhood segregation, a structural factor tied to social determinants of health (SDOH), may create additional barriers to care along the transplant journey.
For providers caring for Black patients and other historically underserved populations, the findings reinforce the need to look beyond individual risk factors and consider the broader barriers affecting access to potentially life-saving treatments.
In the study, researchers analyzed data from 22,223 adult first-time liver transplant candidates listed between 2016 and 2025 at 20 transplant centers that performed living donor liver transplants annually.
The study examined two types of segregation:
Researchers evaluated whether these factors were associated with receiving LDLT.
The study’s findings identified important associations between neighborhood segregation and access to LDLT. Patients who lived in high-segregation neighborhoods had a lower likelihood of receiving LDLT compared with those in lower-segregation neighborhoods. Similarly, patients listed at transplant centers located in high-segregation neighborhoods also had a reduced likelihood of LDLT access.
The study’s findings underscore the notion that segregation is not simply a geographic issue — it reflects decades of policies and systems that can influence:
A patient’s ZIP code should never determine their access to a potentially life-saving treatment. But research increasingly shows that social and environmental conditions influence health outcomes.
Because Black communities have been disproportionately affected by historical and ongoing residential segregation, these findings are particularly relevant when considering broader health equity challenges faced by Black patients. Structural barriers associated with segregation can contribute to delayed diagnosis, fewer specialty referrals, and challenges navigating complex treatment pathways.
For clinicians, it’s critical to understand that barriers to advanced therapies extend far beyond a patient’s individual risk factors.
Living donor liver transplant is a surgical procedure in which a healthy person donates a segment of their liver to a recipient. It can provide an alternative pathway for patients with liver disease by reducing dependence on deceased donor availability. Earlier access to transplant evaluation and donor conversations may improve opportunities for eligible patients.
However, several barriers can make it difficult for some patients to access LDLT, including:
For clinicians treating patients with ESLD, it’s critical to educate patients about their treatment options and share resources on LDLT, so they’re fully aware of their options and can be involved in decisions about their care plan.
When treating patients with liver disease, clinicians should consider the following social determinants as part of transplant care:
It’s also important to encourage earlier referrals. When referrals are delayed, it can limit a patient’s transplant options. Primary care providers and specialists can help identify advanced liver disease earlier and connect patients with transplant resources.
When treating Black patients and other historically underserved populations, it’s critical for all stages of care to deliver culturally responsive communication. Historically, Black patients experienced medical mistreatment, exclusion from research, and ongoing healthcare disparities that have affected trust in healthcare systems. Having clear communication about transplant evaluation, living donation, and treatment options can encourage patients to be more involved in their care and can improve their access to LDLT.
While providers can play a role in improving access to transplant services, it’s a systems-level issue that must be addressed.
The study’s authors recommend the following approaches to get more equitable access:
Improving transplant equity requires more than increasing donor numbers. Health systems must examine whether patients in all communities have equal opportunities to reach, understand, and receive advanced care.
The path to liver transplantation begins long before a patient reaches the operating room. This latest study highlights how neighborhood conditions and health system structures may influence access to life-saving therapies.
For clinicians caring for Black patients and other underserved populations, addressing transplant disparities requires recognizing SDOH as part of clinical care. By strengthening referral pathways, improving outreach, and creating more accessible transplant systems, healthcare organizations can help ensure that geography does not determine who has access to life-saving transplant care.
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