Introduction

The global burden of liver disease continues to increase and now accounts for one in every twenty five deaths worldwide1. Whilst the prevalence of specific aetiologies of liver disease varies regionally, alcohol related liver disease (ALD) and metabolic dysfunction-associated steatotic liver disease (MASLD) are the main drivers of this increasing burden1,2. For patients with chronic liver disease who develop decompensated cirrhosis or hepatocellular carcinoma (HCC), liver transplantation (LT) is the mainstay of curative therapy3. Beyond this, downstaging of HCC has increased the number of patients eligible for transplant4, and non-liver failure and non-HCC indications, such as colorectal and neuroendocrine metastases5,6, continue to emerge increasing the need for accessible LT. Therefore, establishing and delivering a successful LT program is essential for patient survival in these cohorts.

There are numerous factors that need to be considered when developing an LT program. It is essential that there is appropriate multidisciplinary expertise accompanied by necessary resources to optimise patient selection and management in the pre-, peri- and post-operative stages. With the advent of machine perfusion, the opportunity to utilise marginal grafts, which would otherwise have been discarded, continues to increase the cadaveric donor pool7,8. Progressive adoption of living donor LT in countries that have historically depended on deceased donation may further expand options for recipients to meet rising demand with comparable outcomes9,10. However, there are inherent challenges in delivering a LT program. Ensuring equitable access to transplantation, whilst reducing avoidable patient mortality, is a complicated, multifaceted process. It is impacted by the patient population, including cultural acceptability, healthcare organisation, implementation practices, and resource utilisation. Consequentially, LT programs vary significantly in a number of specific facets. Most importantly, the relative success of any LT program is founded on its relationship with the donor population. The acceptability of the program to this critical stakeholder is paramount to the successful delivery of a LT program.

In this review, we will discuss the potential challenges and solutions in providing access to LT for those with established decompensated cirrhosis, HCC, or variant syndromes listed by accepted criteria. We highlight three geographically distinct and philosophically unique health systems as examples of this variation; the United Kingdom (UK), the United States (US), and India. These examples have also been chosen due to the contrast in programs developed in public and private healthcare settings, as well as differences in proportions of cadaveric and living donor populations. We will explore the potential reasons for the design of programs in each setting and discuss potential lessons learnt from their LT experiences, including the public’s perceptions of each program. The role of transplantation for acute liver failure (ALF) and acute-on-chronic liver failure (ACLF), is not covered as these are even more heterogeneous and nuanced in delivery across regions. Prognostic models developed in order to allocate grafts once a patient has been listed for LT and their limitations are also not discussed, as these have been covered in depth in previous reviews11,12.

Section 1–Comparing the UK, US, and Indian LT programs

The UK

The UK healthcare system is free to the patient at the point of care. LT in the UK is overseen by National Health Service (NHS) Blood and Transplant and delivered from seven LT centres13. Each of seven transplant centres across the UK is responsible for assessing and accepting patients onto the national transplant waiting list. Patients with decompensated cirrhosis access LT through the following pathways: a UK model for End-stage Liver Disease (UKELD) score of above 49, modified Milan criteria for patients with HCC, and then the ‘variant syndrome pathway which encompasses other manifestations of end-stage liver disease (e.g., hepatopulmonary syndrome) who have a UKELD score less than 49 (Table 1)14,15. ALD is the leading aetiology of liver disease transplanted, with the proportion of patients with MASLD continuing to increase. Between April 2023 and April 2024, 885 liver transplants were performed, reflecting 12.9 liver transplants per million population16,17. Regarding graft utilisation, 66.3% were donation after brain death (DBD) transplants, 30.2% were donation after cardiac death (DCD) transplants, and 3.5% were living donor transplants (LDLT). Time from listing to transplantation for patients receiving a deceased donor graft is as follows: 52% were transplanted within 6 months, 60% within 1 year, and 69% at 2 years16. In March 2024, there were 678 patients active on the liver transplant waiting list across the UK16. One-year survival following elective listing was 88.5% (one-year post LT survival 95.2%), with five-year survival post-elective listing being 75.5% (five-year post LT survival 82.9%)16.

Table 1 Minimum listing criteria for LT113,114,115,116,117
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The US

The US system of liver transplantation is governed by the United Network for Organ Sharing (UNOS), a non-profit organisation that oversees the Organ Procurement and Transplantation Network (OPTN), responsible for organ procurement, matching, and allocation in the US. UNOS is now divided into 11 geographical areas across the entirety of the US; allocation is based on an acuity circle model using clinical urgency and geographical distance between donor and recipient hospitals18. Although these regions work more independently than in the UK, they must all adhere to the standards and guidance outlined by UNOS—listing is based on Model for End-stage Liver disease (MELD) 3.0 score, with exception points for aetiologies or sequelae of decompensated cirrhosis for which LT is indicated, but may have lower MELD scores (Table 1). The US performs the greatest number of liver transplants compared to any other country with 10,528 performed in 2023, which is 30.5 per million population18,19. This is delivered through 142 active transplant centres; 93.7% of liver transplants were from deceased donors (65% DBD donors and 35% DCD donors), with the remainder from LDLT18,20. Similar to the UK and other Western countries, the prevalence of patients transplanted with ALD and MASLD continues to increase but there remains a significant population of patients with viral hepatitis20. Time from elective listing to LT for patients listed in 2022 was as follows; 41.7%% within 3 months, 48.4%% within 6 months, and 58.2%% within 1 year20. Pre-LT mortality is reported as 12.9 deaths per 100 years, with 1-year post LT survival 93.5% and five-year post LT survival 81%20.

India

In contrast to the UK and USA, the main aetiology of liver disease for patients undergoing LT in India is viral hepatitis, but there is an evolving shift in disease burden with the increasing prevalence of ALD and MASLD21. While there are over 450 approved transplant centres across the country, only an estimated 150 may be classified as ‘active’ (performing over 5 LT / year)21,22. Historically, activity has been mainly centred around New Delhi and Tamil Nadu, with large areas in the North and East less well serviced23,24. Although LT activity predominantly depends on living donation, there is a slowly growing deceased donor program25. Currently, deceased donation is solely from DBD donors, with no current agreed set criteria and only a few unpublished reports of DCD LT mentioned in the literature26. According to the Global Observatory on Donation and Transplantation in 2023, the total number of transplants performed was 4491; out of which the majority of 3643 were LDLT (81.1%)19. This equates to 3.14 liver transplants per million inhabitants19. It has been estimated in the past that over 20,000 are awaiting liver transplant each year, which is likely to be an underestimation of the true disease burden27. The Indian Liver Transplant Registry was created in 2019 and aims to collect data for prospective outcomes across the country. It is not currently mandatory for centres to contribute to this registry, although it is strongly encouraged, making it difficult to examine national data21.

Comparison of LT provision

Across these 3 countries, healthcare provision and access to transplant services are intrinsically different (Fig. 1). The UK NHS works as a public government-funded system. Whilst private healthcare is available, it is relatively rare in the context of liver transplant. All costs of consultation, surgery, and in-hospital medication are covered by the NHS, although patients will still experience a significant loss of earnings, outpatient prescription costs, and associated travel costs as they progress through the process of LT.

Fig. 1
figure 1

Comparison of UK, US, and Indian liver transplant programs.

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The US is an insurance-based system, with most people under age 65 either insured through their workplace or with independently purchased insurance. Medicare, a federal insurance program, is available to patients over 65 or with certain chronic conditions who can receive healthcare in approved facilities but will still have to contribute to some costs. Low-income individuals can be covered by Medicaid, a state healthcare provision program.

India primarily operates through a private healthcare system with only a few hospitals offering publicly funded liver transplant services28. In 2023, in the state of Tamil Nadu, 8.8% of all deceased donor LTs were performed for free in public sector hospitals29. Whilst private pay-from-pocket healthcare has historically only been available to those with sufficient means, the central and several state governments, including Tamil Nadu, Andhra Pradesh, and Gujarat, now sponsor a fully inclusive healthcare insurance for low-income individuals. This includes transplantation (adult and paediatric, including LDLT) at any approved private hospital in the state29.

As mentioned, the UK and US depend on predominantly deceased donor grafts, and there is a recognised mismatch in demand and supply. There has been a move in recent years to widen the pool of potential cadaveric donors through the use of extended criteria, included those with previous exposure to viruses as well as grafts that would previously have been considered marginal. The UK has been at the forefront of the utilisation of DCD grafts in terms of the proportion of overall transplant numbers compared to other countries30. The historic concerns regarding the utilisation of DCD organs are related to the increased risk of cholangiopathy and primary graft nonfunction31. However, recent data have demonstrated that recipient mortality is comparable between patients receiving DCD and DBD grafts, with significant improvement in DCD graft survival in recent years32,33. The opioid epidemic across the US has led to a sustained increase in the availability of deceased grafts from younger donors34,35. Over the last decade, there has been a greater than 300% increase in deceased donors who have drug intoxication listed as cause of death18.

Organ retrieval is a critical step in LT and has evolved into a subspecialty in its own right. Strategies have been developed to reduce the impact of travel time, which has historically impacted on graft utility, particularly across large geographical areas like the US. This is coordinated by NHS Blood and Transplant (NHSBT) and the National Organ Retrieval Service (NORS) in the UK. In the US, organ procurement organisations (OPOs) are non-for-profit organisations that are responsible for assessing donors and making organ offers. India has in the past worked on a more fragmented basis, but with the creation of the National Organ Tissue Transplant Organisation (NOTTO), registered hospitals can be part of a country-wide network aiming to improve access to grafts23.

In the US, the discard rate for all types of deceased organs (DBD and DCD) was 9.7% in 2023. This is reported to be higher for DCD offers specifically, around 30%36,37. These findings are similar in the UK; in 2025, 80% of all deceased organs retrieved were transplanted, and 71% of DCD organs retrieved were transplanted38. Data from India is currently not available. It has been demonstrated that there is international variation in guidelines regarding cadaveric donation, with variations in maximum donor age, warm and cold ischaemia, which are likely further impacted on by assessments of graft steatosis and logistical challenges in delivering LT (for example, ability to transfer organ to transplanting site, availability of transplanting team, etc)30. Developing methods to optimise organ utilisation has therefore been an area of focus for the community.

In recent years, advanced perfusion techniques such as normothermic regional perfusion (NRP) and ex-situ machine perfusion (normothermic or hypothermic) have been developed to try to reduce organ discard rates to meet the increasing demand for LT. These have been shown to reduce ischaemic cholangiopathy and increase graft quality, allowing use of more marginal DCD grafts39,40. NRP is now the standard of care in many European countries and has been more widely used across the US in recent years39. Normothermic machine perfusion (NMP) was approved for use in the UK in 2019 and has now been adopted by LT centres across the country; it has since also been used more commonly in the US after FDA approval in 2021. There is limited data to indicate to what extent these techniques have been adopted in India41.

Organ discard rates have and will likely further reduce with the advancement of this technology30. However, this also relies on investment, expertise and infrastructure, which includes travel time, to deliver these techniques optimally. LDLT in the UK remains relatively uncommon, with a limited number of centres performing a few living donor transplants per year. The reasons for this are likely multifactorial. The UK has a robust public nationalised health service and is geographically a relatively small, densely populated land mass with good travel infrastructure. Therefore, there has historically been limited progress in developing a living donor program due to relatively good access to cadaveric grafts. Initial outcomes from other countries, such as the US and in Asia demonstrate a learning curve with a relatively high rate of complication and donor risk, which improves with experience42,43. This may also influence UK LT centres in regards to the risk of developing a living donor program. Although living donation only makes up 5-6% of transplants in the US, centres have considerably more experience compared to the UK. One study reported that between 2002 and 2020, 97 centres performed at least one LDLT44. LDLT has an advantage for recipients who often can be transplanted with lower MELD scores in planned elective procedures. Mitigating the risk to donors depends on a rigorous selection process with a thorough multidisciplinary team review. Outcomes at 1, 5, and 10 years are comparable, if not superior to, deceased donation. This may be due to several reasons, including reduced time on the waiting list and subsequent waiting list mortality, as well as a degree of selection bias with the transplanted population not directly comparable to that of deceased donor programs45,46. Fundamentally, LDLT provides LT in a truly elective setting, which allows for planning, including prehabilitation, to optimise patient outcomes. The Indian LT program is reliant on living donation. This is due to the vast geographical area, lack of travel infrastructure, and a well-established decentralised healthcare system, which has made directed living donation a necessity47,48,49. As such, India have had to innovate to maximise the living donor pool with ABO incompatible LT increasing in number in recent years50. Recipients of living donor grafts can be registered in several states, leading to some patients with the means to do so travelling to states with more accessible LT services. Every living donor other than first degree relatives must be reviewed by an ethics committee responsible for ensuring there is no exploitation of the donor51. This review is also necessary for all potential non-Indian national recipients.

The deceased donor program in India was formed in 2011 but has seen slow adoption, with significant regional variation across the country25. Beyond the pervasive public mistrust, inconsistent coordination and policy implementation across administrative tiers have hindered a nationwide scaling of deceased donation. Nevertheless, persistent and concentrated efforts by all the stakeholders have yielded results, with improving donation rates over the past two decades, rising from zero deceased donor LT in 2000 to 0.47/million people in 2019, although these initiatives remain unevenly distributed52. NOTTO is responsible for final oversight of this process, with individual states (SOTTO) having direct responsibility for maintenance of the waiting list and deceased donor registry25. Awareness and acceptance of organ donation remain a key issue hampering development of deceased donor transplant, including difficulties surrounding the ethics of brain-stem death legislation.48,53.In addition, cultural beliefs and religious ambiguity on deceased donation across the wider Asian continent also likely contributes to its limited adoption48.

Section 2–Barriers in providing equity in access to LT

The impact of ethnicity on access to LT

Despite efforts to ensure an equitable listing process and organ allocation system, disparities still impact specific groups of patients. Inequity due to ethnicity has been widely noted within the transplantation process and has been most studied in the US due to the diversity of the population. Differences in experiences amongst ethnic minorities are often framed in the wider context of socioeconomic factors and interaction with the healthcare system. Patients from ethnic minorities have a higher burden of certain liver diseases due to both genetic and social factors54,55,56. However, several studies have suggested that access to LT is limited for several reasons. Medical mistrust and perceived prejudice may lead certain ethnic groups to be less likely to access healthcare57,58. A US study has previously demonstrated that amongst newly diagnosed HCC patients, Black and Hispanic patients were more likely to have concerns about their diagnosis and the proposed treatment59. Willingness to undergo LT is a necessity for LT, and those patients who do not engage due to mistrust likely self-select themselves to not being transplanted. This is likely amongst the reasons for findings demonstrating that compared to White patients, African American and Hispanic patients are less likely to undergo LT with late presentations and higher mortality more frequently observed amongst African American patients60,61,62. Ethnic minorities have also been shown to be less likely to be an organ donor and less likely to receive a living donor liver transplant in the US63. One qualitative study, which involved interviewing transplant team members involved in LT assessment, found that inequity may stem from lack of resources to cater to patients from ethnic minorities or to address social determinants of health. As the decision to list for transplant is centre-based it may also depend on any bias which exists both systemically and at the level of the transplant MDT64. It is essential that the LT centre engages with its entire local population to maximise donation and to prevent barriers developing in providing LT to those who require it.

These findings are not unique to the US. In the UK, disparities are also recognised to exist amongst different ethnic groups on the LT waiting list. From 2023-2024, 7% of deceased liver donors were from ethnic minority groups, whilst representing 19% of the liver transplant waiting list65. Median time to transplant has also been shown to be significantly shorter for white patients compared to some other ethnic groups65. Lack of donors from less well-represented communities may have an impact on availability of blood-group-matched grafts. Raising awareness of transplantation and organ donation within these communities is a key factor in tackling this inequity. Although more work has been done in the US, increasing work is ongoing in the UK, particularly amongst Asian donors66. Limited data exists on the relationship between ethnicity and inequity in liver transplant in India.

Social determinants of health and the way that they interact are complex, and interventions to tackle inequity are likely required at several levels. This not only includes developing national strategy, but developing an understanding and an approach at both local and individual levels. Recent efforts to eliminate HCV have involved innovative practices, including principle of decentralisation and micro-elimination to target “difficult-to-reach” groups of patients with challenging engagement67. On an individual level, peer support has been shown to be an invaluable strategy to improve engagement in both hepatitis B (HBV) and C patient populations who may otherwise have significant barriers to care68,69. Community support workers who target and build relationships with certain communities to facilitate testing and treatment have also yielded excellent outcomes. This has been studied in the US within immigrant populations with HBV in the state of Florida and within Native American populations70,71. In the US, an outreach program targeting patients from Hispanic backgrounds, which included specific educational material in Spanish, has been shown to increase referrals for LT72. However, many patients were ineligible for LT due to financial reasons. It is critical that further work is undertaken to understand how access to LT could be directly improved by addressing underlying socioeconomic factors.

The financial burden of LT

LT in India often is historically thought of being only available to the wealthy, as the average cost of liver transplant is out of reach of most patients, including the middle class23,28. Over 95% transplantation is performed at private hospitals with programs being run by private stakeholders71. Given the cost of liver transplant in India is around $25,000–$30,000, the vast majority of patients are unable to afford this life saving intervention71. Public hospitals, which usually cater to patients of lower socioeconomic status, are overburdened and have been slower at developing LT programs, and in 2020, only 5 consistently were offering LT28,71. Poor performing centres face closure before gaining momentum, and without the incentives of the private sector, can struggle to recruit staff23,28,71. Deceased donor programs have mainly existed in cities in the South or West, with the rest of the country being less well serviced23.

LT in India costs nearly 30 times lower than published figures from the United States; yet, it remained beyond the means of most Indians29,73. While it should be conceded that transplantation in India may not be available to all, access to transplant for the underprivileged has greatly improved over the past decade. More recently, there have been several government initiatives to support those from low-income backgrounds, including fully sponsored LT (including LDLTs) in approved private-sector hospitals, with support extending on to their post-operative medical expenses29. Further, aid from non-governmental organisations, and other modalities such as crowd-funding, has enabled a growing number of Indian patients afford transplantation74.

Travel to India, which is rich in experience and resources, is commonplace from neighbouring countries where transplantation services are less well developed. It is reported that up to 30% of living donor transplants performed are recipients from abroad, often regarded as medical tourism23,28,51. Nonetheless, equating transplant tourism with organ commerce is erroneous. For patients from neighbouring low-income countries, India remains a more financially viable destination for transplantation compared to the West. Even governments in the Middle East, where transplantation costs are more affordable than the West, are increasingly looking to develop direct referral pathways with Indian transplant units29. Some larger centres in India have established partnerships with their counterparts in neighbouring countries to facilitate the referral of challenging cases from less experienced centres28. Foreign recipients must provide their own living donor and are subject to strict review processes; they may only be offered a deceased donor graft if there is no suitable Indian recipient, which would be an extremely rare scenario given the long waitlist25,28. In the state of Tamil Nadu, which has year-on-year one of the highest numbers of deceased donations in India, no liver or kidney has been allocated to a foreign national in the past 5 years29,75.

The US system is insurance based with patients either being insured privately, or through Medicare or Medicaid. Even with Medicare coverage for >65 years or certain health conditions, patients need to cover some additional costs. In 2023, 18.9% of US citizens were covered by Medicaid, a government healthcare insurance program subsidising patients from low-income households76. Within the US insurance-based system, there are clear disparities between groups of patients. The use of Medicare or Medicaid compared to private insurance has been shown to correlate to more severe organ failure at time of listing, longer wait time for LT, and worse post-transplant outcomes compared to privately insured patients77,78,79. The expansion of Medicaid and the Affordable Care Act 2014 has seen a rise in the number of Medicaid beneficiaries undergoing liver transplant without any increase in waitlist mortality, suggesting that more widely available public health care may have made liver transplant more accessible to disadvantaged patients80.

In the UK, a predominately publicly funded healthcare system presents its own unique problems in relation to overstretched services and the impact on quality of care. The prevalence of cirrhosis in the UK is rising due to increasing alcohol use and obesity, which are largely preventable factors81. Given that liver disease often is silent until advanced stage, increasing focus has been on public health strategies that target contributing factors and improved early detection of high-risk individuals82,83. However, research by the British Liver Trust has found significant discrepancies in robust pathways for early detection across the country, with large areas without effective processes for early detection, leading to a “postcode lottery” scenario84. A ‘population health’ approach will likely reduce the prevalence of steatotic liver disease, which is the major driver of liver-related morbidity and mortality. There are well-described capacity challenges in delivering healthcare worldwide, particularly following the COVID-19 pandemic, with this most pronounced within the public healthcare sector. It is vital that a patient’s social and financial status should not dictate their access to a lifesaving liver transplantation. Meeting the rising demand, driven by increasing prevalence of liver disease, within stretched public sector healthcare will require innovative solutions. This will likely involve increasing healthcare spending, developing technology as well as considering the role of privatisation in some areas without passing costs on the patient. Specialist hepatology care has already had to adapt to these growing pressures through increased use of telemedicine and virtual consultations for HCC surveillance although further work is required to make care as accessible as possible. Whilst it may be thought that patients with liver disease are less likely to engaged with digital health care solutions, recent work has demonstrated that this cohort of patients will engage with technology85. Further work is required to understand how to maximise the use of these solutions as hepatology continues to modernise the delivery of healthcare. It is clear that state-sponsored LT increases equitable access to LT. However, this requires sustained investment to ensure long-term viability of the program. Developing partnerships between both private and state funded facilities may be amongst the solutions to increase access to LT.

The impact of distance from a LT centre on access

It has been proposed that distance from transplant centre affects access to care and therefore patient outcomes. Goldberg et al. demonstrated that there is significant variability in mortality from liver disease between states and counties in the US, attributable to both markers of poverty and geographical distance from transplant centre86. One large retrospective study on veterans in the US found that with increasing distance from transplant centre there was a significantly lower probability of listing, receiving a liver transplant, and a higher mortality87. This finding was also echoed in a large UK multicentre retrospective demonstrating this phenomenon is not US specific88. Availability of local gastroenterology or hepatology services may also compound this finding, as potential transplant candidates may be identified and referred earlier at centres with dedicated liver services89.

Creating further LT centres has been hypothesised as a means to address this problem88. However, the financial implications of this, particularly if state-funded, need to be considered. Setting up a new transplant centre requires significant resources and likely would take considerable time to build up the experience across the multidisciplinary. A previous UK study has demonstrated that distance from an LT centre impacts patients referred for LT assessment with decompensated cirrhosis, but not hepatocellular carcinoma90. The likely reason for this is the formal cancer referral network that exists to reduce time from diagnosis to treatment, which means patients with a suspected liver cancer undergo a mandatory review by a specialist multidisciplinary team. A more formal referral pathway for patients with decompensated cirrhosis could simplify the referral process and reduce variability in access to specialist interventions, including LT. This would allow for review of patients with complications of clinically significant portal hypertension earlier in their disease course for LT, as well as other non-LT management strategies such as transjugular intrahepatic portosystemic shunts, prior to the onset of sarcopenia and worsening frailty, which is associated with poorer LT and non-LT intervention outcomes91. Several transplant centres in the UK use a hub and spoke approach, with the development of outreach to satellite centres feeding into a central transplant centre. This approach has been shown to reduce wait time and improve patient access to LT92,93. Strengthening these networks and pathways, as opposed to creating further LT centres could be a more financially viable approach to improve patient access to LT, which could be replicated across nations.

Incorporating technology into the transplant assessment process has been shown to be a useful tool in addressing the issue of distance and has become commonplace as a consequence of the COVID pandemic. Telemedicine has been demonstrated to reduce time to evaluation and listing in the US94. In the UK, virtual LT assessment was demonstrated to have comparable outcomes in regards to likelihood of listing and short-term LT outcomes in a highly selected population95. Technological advancement presents an exciting opportunity to enhance patient care, especially with the emergence of artificial intelligence. However, not all patients will be comfortable with the use of technology, and care must be taken to alienate this group, thereby increasing inequity. Studies have shown that older age, lower levels of education, or socioeconomic status all influence how likely a patient is to be able to interact with telemedicine96.

Given India’s reliance on LDLT, proximity to a transplant centre does not appear to significantly influence access to care. Instead, socioeconomic status and awareness of treatment options emerge as more critical determinants of access, while also serving as barriers to timely referral. In contrast, deceased donor LT services remain concentrated predominantly in southern and western India. Consequently, prospective recipients, regardless of their city of residence, must relocate near transplant units to facilitate urgent care for critically ill patients and ensure availability when they reach the top of the waiting list. This regional imbalance in service provision has thus far hindered meaningful discussion on equitable access to DDLT across India.

Section 3–The donating public’s perception of transplantation

Liver transplantation is dependent on the public’s engagement and support for organ donation, so any allocation system must be acceptable in the eyes of both potential donors and recipients. Potential organ donations may be seen as a community-held resource to benefit society as a whole and not just the individual. There have been few studies looking at the public’s view of organ allocation. In the UK, a survey of 1000 patients, 200 GPs, and 100 gastroenterologists was previously undertaken to understand different perceptions on which patients should be prioritised for LT97. This showed that the public felt younger age, clinical outcome, and time on waiting list as the most important factors. Involvement of alcohol and illicit drugs was ubiquitously ranked low when prioritising transplant, findings which have been reiterated in other surveys and studies across nations.98,99, Given the prevalence of disorders associated with drug and alcohol use in causing end-stage liver disease, it is critical to understand the public’s perception of these issues as to not create further barriers to LT. Similar to substance misuse, it can be argued that obesity is often mis-attributed to personal choice and, therefore, it may be fair to speculate the public may also view these individuals negatively in the context of LT. There are legitimate concerns in this patient cohort, such as increased anaesthetic risk, post-operative complications and the risks associated with co-existing sarcopenia. However, several studies have demonstrated limited impact on long-term post-transplant outcomes100,101. Both substance misuse and obesity are closely linked to social deprivation. There is evidence that obese patients are underrepresented on the LT waitlist with longer waiting times102.

There is well-established evidence that patients with liver disease of various aetiologies experience stigma related to their health condition. The Stigma Survey from the British Liver Trust revealed that 73% of people with liver disease had experienced stigma of some kind103. The survey demonstrated that 35% of respondents had been told that people who drink alcohol should not be entitled to a liver transplant. According to the survey, stigma had stopped 29% of respondents accessing healthcare. Stigma as a significant barrier to healthcare engagement, which means that more patients may progress to end-stage liver disease without seeking help and have less access to specialist care and transplant services. Addressing stigma is essential to improve early access to services and treatments to reduce the increasing morbidity and mortality from liver disease.

Given the public’s negative perception of ALD, there have been a number of controversies surrounding transplantation for this aetiology. In the UK a period of abstinence rule is typically required prior to LT assessment. Whilst this is to potentially allow liver function to recompensate, it also allows for assessment of abstinence. However, the risk in implicating such a policy is that it removes the potential survival benefit offered by LT in alcohol related hepatitis104. It is notable that the UK LT pilot evaluation in alcohol related hepatitis only registered 3 patients, of which none underwent LT (1 death, 2 delisted due to clinical improvement)105. Whilst this may reflect strict inclusion/exclusion criteria, it also may reflect cultural perceptions regarding the risk of return to alcohol use post LT. It is interesting to note that both European and US studies are reporting acceptable longer-term survival and abstinence in patients who have undergone LT for alcohol-related hepatitis106,107. It is critical to continue to build the evidence base and communicate this effectively with the general public and healthcare professionals to challenge the stigma surrounding alcohol and LT. It is also vitally important to ensure that appropriate substance misuse and alcohol services are provided to ensure patients are supported in abstinence post-LT to achieve these excellent outcomes.

Patient age is another important consideration when prioritising organs, with some literature suggesting that the public favours prioritising younger patients99. The argument for this is that this cohort may have the opportunity to gain more life years from a transplant. Recently, there has been criticism of the UK organ allocation system, which can leave younger patients waiting longer for transplantation, which has caused public concern due to the perception that their disease is not due to lifestyle factors108. Although literature on patient outcomes is conflicting, with some studies demonstrating inferior outcomes in patients who are younger, generally age in isolation is not a strong predictor of inferior outcomes compared to frailty and associated co-morbidities109,110,111. This suggests that careful patient selection is essential to ensure optimum outcomes. Meticulous work-up and individualised decisions by an experienced MDT are key to acceptability and avoidance of futility. As older patients often have a higher waitlist mortality or chance of being delisted while waiting, it can be argued they do derive comparable benefit to younger patients110. Organ allocation systems are complex, and in the UK take into account age of donor and recipient as well as various other factors. However, measuring the impact of waiting on quality of life is challenging, and as such, it is not currently considering within allocation algorithms110,111. Clearly, a balance must be struck between patient need and graft utility when considering organ allocation, and that this needs to be perceived as equitable across different patient cohorts. Further work is required to understand the optimal way to achieve this, which is acceptable to the donating public of each individual LT program.

Compared to US and UK, there is little data regarding public perception of organ donation and transplantation in India. A cross-sectional survey conducted among 996 medical students and junior doctors in India to assess their knowledge, attitudes, and perceptions of organ donation and transplantation showed that only 11.9% had previous exposure to transplant, while merely 19.3% were aware of the low organ donation rate in India112. Most (84.0%), however, felt that the subject should be strictly implemented in the undergraduate and postgraduate medical curriculum, viewing this as crucial for addressing prevalent misconceptions, knowledge gaps, and religious preconceptions among both non-transplant healthcare professionals and the general public. While India continues to trail Western nations in public awareness of LT, there is growing recognition across all levels of the healthcare community about the need to advance organ donation initiatives.

Conclusions

There are significant challenges in ensuring equity in access to LT, and no ubiquitous global solution seems either desirable or achievable. Whilst the UK, US, and India all have their own inherent challenges in delivering transplant programs, lessons can be learnt that are transferable across multiple systems to reduce inequity. Whilst infrastructure and funding are important issues that require attention, engaging the local population with the LT program is critical for successful delivery of equitable care. Responding to the ever-changing pool of potential recipients and donors whilst embracing novel ways of working, including the use of technology, is required to deliver an effective patient-focused, cost-efficient liver transplant program.