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“Although more than 10% of the US population lives in rural areas, most transplant centers are in urban centers,” researchers wrote in JAMA Network Open. “This unequal distribution of transplant centers is associated with an increased risk of overall mortality. Recent modifications of organ allocation policy for donated livers have sought to reduce geographic disparities in access to transplants and, thereby, to reduce mortality from liver disease among patients listed for liver transplant.”

Michael R. Charlton, MBBS, and colleagues examined temporal trends and geographic variations in liver-related mortality (LRM) and liver transplant in the US. They assessed the frequencies of organ transplants by state with respect to LRM based on data from the Scientific Registry of Transplant Recipients (SRTR) and CDC Wide-Ranging Online Data for Epidemiologic Research (WONDER) databases. Further, state residence data for organ donors and recipients were used to analyze trends in LRM.

The primary outcomes and measures were liver-related mortality in 2018 and 2021, overall and by state, and the rates of liver transplants by state of residence of recipient and donor.

Liver Mortality Rates & Transplant Outcomes

In 2021, the US had 93,418 incidences of LRM, representing a rate of 28.1 per 100,000 people. This was an increase of 19.1% compared with rates seen in 2018, immediately before the COVID-19 pandemic, in which the incidences of LRM were 77,282, representing 23.6 per 100,000 individuals. Moreover, in 2021, LRM varied significantly across states, ranging from 18.4 deaths per 100,000 people in Utah to 65.9 per 100,000 in New Mexico.

On average, there were 7.2 liver-related deaths per transplant in the states with the lowest mortality rates compared to 21.5 in states with the highest rates. Ten primarily rural states did not have liver transplant centers. Further, states with the highest LRM had meaningfully lower rates of liver transplants from in-state donors (13.0%) compared to states with the lowest mortality rates (35.2%).

The authors noted that LRM rates have surged significantly since the COVID-19 pandemic, with substantial differences across states.

“These findings highlight apparent geographic disparities in access to liver transplants that allocation policy cannot address, raising important questions about the need for new strategies to ensure fair and balanced access to liver transplants for all patients, regardless of their location,” Dr. Charlton and colleagues wrote.