Background: Non-alcoholic steatohepatitis (NASH) is a rapidly-growing indication for liver transplantation (LT) in the West. Gender disparities in LT rates are well-established. We sought to analyze gender disparities amongst NASH patients with cirrhosis and their access to LT in a contemporary cohort.

Methods: We used data from scientific registry of transplant recipient to assess gender and ethnic differences in patients listed for LT. Adult patients transplanted from August 1997 to June 2021 were included. Inferential statistics were used to evaluate differences with univariate and multivariate comparisons. Regression modeling using a forward conditional approach was performed.

Results: During the study time period, we evaluated 12,844 LT for NASH cirrhosis.  Women were transplanted at a lower rate (46.5% vs 53.5%; p<0.001) and at a higher MELD (23.8 vs 22.6; p<0.001) than men. Minority women were transplanted at a higher MELD (26.1 vs 23.1; p<0.001) than white women and minority men (26.1 vs 24.8; p<0.001). Furthermore, minority women with NASH have a lower BMI (32.2 vs 32.1; p=0.002) on the waitlist compared to white women but minority women with NASH have a higher mortality (21% vs 18%; p=0.006) on the wait list compared to white women. Patient survival for women at 1, 3, and 5 years was 90.3%, 83.4%, and 77.3%respectively, and graft survival was 95.9%, 94.4%, and 93.3%, respectively.  By comparison, patient survival for men at 1, 3, and 5 years was 93.6%, 87.1%, and 80.3%, respectively and graft survival was 97.6%, 95.6%, and 93.8%, respectively. Minority women patient survival at 1, 3, and 5 years was 89.3%, 82.2%, and 76.0%, respectively. Minority women graft survival at 1, 3, and 5 years was 95.4%, 94.1%, and 92.2%, respectively. Non-minority women patient survival at 1, 3, and 5 years was 93.9%, 87.4%, and 79.2%, respectively. Non-minority women graft survival at 1, 3, and 5 years was 97.0%, 94.0%, and 91.6%, respectively. Except for 3-yr graft survival, graft and patient survivals at all three time points were significantly different (p<0.001) between minority and non-minority women.  Multivariable analysis for graft loss[SO1]  in women showed that age, creatinine, earlier transplant year, and immunosuppression all were significantly (p<0.04) associated with graft loss, but minority status was not.

Conclusions: Women with NASH cirrhosis have a higher MELD at LT than men. Minority women with NASH in particular have a higher MELD and Cr at time of transplantation compared to white women. Minority women are most vulnerable on the LT wait list.  Even after LT, minority women exhibit worse outcomes compared to men or white women.  Further work is necessary to elucidate these gender and racial difference after LT.