Sex- and Age-Related Differences Among Liver Transplant Patients: A Narrative Review

Liver transplantation (LT) remains the definitive therapy for end-stage liver disease, yet outcomes are increasingly recognized to depend upon factors beyond disease severity alone. Sex-, gender-, and age-related differences permeate the entire transplant process, from access to long-term survival. Women experience reduced access to LT, including lower listing rates, prolonged waiting times, and elevated waitlist mortality. While some disparities reflect biological differences-such as body size and creatinine levels-gender-related factors, including socioeconomic status, healthcare accessibility, and referral patterns, contribute substantially. Current allocation systems, notably Model for End-Stage Liver Disease scoring system-based algorithms, capture only partially these dimensions. Concurrently, advancing donor and recipient age has reshaped transplant practice, with outcomes more closely tied to physiological reserve than chronological age alone. Beyond recipient characteristics, donor sex and age, together with donor-recipient matching, significantly impact graft survival and post-LT complications through mechanisms involving hormonal signaling, immune competence, and metabolic capacity. Critically, sex, gender, and age operate as intersecting determinants rather than isolated variables. Emerging sex-adjusted allocation models demonstrate improved predictive performance; nevertheless, persistent disparities suggest that structural inequities remain inadequately addressed. This review synthesizes current evidence across the LT continuum and highlights the imperatives to integrate biological and structural determinants into allocation policy, thereby advancing both equity and clinical outcomes.