Disparities in deceased-donor liver transplantation occur across referral, listing, allocation, and post-transplant care. Improving equity requires knowing at which stages inequity arises and how those stages interact. We developed a multi-stage care cascade to trace inequity and assessed whether the Model for End-Stage Liver Disease (MELD) and UK Transplant Benefit Score systems permit external audit.

MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library were searched to 31 March 2026 for demographic, socioeconomic, geographic, and algorithmic exposures in adult deceased-donor liver transplantation. We used PRISMA-guided stage-based narrative synthesis and transparency appraisal.

Of 37 included sources, 31 were from the United States.

Distance (OR 0.94 per doubling; 95% CI 0.92–0.96) and deprivation (sHR 0.72 per higher ADI score band; 95% CI 0.67–0.76) were linked to lower waitlisting; Hispanic candidates with NASH (sHR 0.79; 95% CI 0.75–0.84) to lower transplantation rates, with higher waitlist mortality (sHR 1.17; 95% CI 1.05–1.31). MELD 3.0 was associated with an early relative gain for women (sex-by-period interaction OR 1.36; 95% CI 1.16–1.60) that attenuated after three months. Certainty was low for these findings. Published formulae enabled scrutiny of model structure, but clinical inputs and upstream decisions were less auditable.

In this predominantly US evidence base, disparities were reported at multiple stages, but no included study followed the same patients across stages, so whether disadvantage accumulates is unknown. Mapping where inequities have been reported across the care cascade identifies stages for equity assessment and targeted intervention.