Global Disparities in Liver Transplantation Relative to the Burden of Cirrhosis and Other Chronic Liver Diseases (2000–2023)

BACKGROUND: Global access to liver transplantation (LT) remains highly unequal. We analyzed worldwide patterns of LT activity, donor source, and their alignment with disease burden across sociodemographic strata. METHODS: We combined country-level LT data from the Global Observatory on Donation and Transplantation (2000-2023) with prevalence and mortality estimates for cirrhosis and other chronic liver diseases from the Global Burden of Disease 2021 Study (2000-2021). LT rates and donor source were analyzed across Sociodemographic Index (SDI) categories. LT capacity was benchmarked against age-standardized prevalence rates and age-standardized mortality rates. Associations between LT intensity and the mortality-to-prevalence ratio were evaluated using pooled correlations, within-country analyses, and 2-way fixed-effects models adjusting for country-year and calendar year. RESULTS: From 2000 to 2023, LT activity was concentrated in high-SDI countries, whereas low-SDI countries relied almost exclusively on living donation but had extremely low overall LT rates. When benchmarked against age-standardized prevalence rates and age-standardized mortality rates, LT capacity showed a strong inverse gradient across SDI, with substantial heterogeneity among high- and middle-SDI countries. Within-country and 2-way fixed-effects models demonstrated a small but significant inverse association, indicating that higher LT activity was associated with lower mortality relative to disease prevalence at the population level. CONCLUSIONS: Global LT capacity remains poorly aligned with the burden of cirrhosis and other chronic liver diseases and is driven more by health system development than epidemiological need. Although prevention remains central, incremental expansion of equitable LT infrastructure may be associated with modest improvement in population-level mortality relative to disease prevalence.