*Purpose: While disparities in access to liver transplant are well documented among adults, differences in access to the waitlist for children in remote or underserved communities remains incompletely understood.

*Methods: Centers for Disease Control county-level records of pediatric liver disease deaths from 2002-2016 were compared with SRTR records of waitlist additions. Sociodemographic vulnerability was assessed by county Community Health Score (CHS), and proximity to care approximated by the presence of a high volume (>100/study period) liver transplant center in-state.

*Results: From 2002-2016, 9112 patients were listed and 2138 children died of liver disease. Children in underserved (CHS 30-40) counties had observed death rates 30% higher than those in more fortunate (CHS 0-10) areas (2.23 vs. 1.75 deaths per million person-years, p < 0.001), and were 27% less likely to be waitlisted than CHS 0-10 counterparts (p < 0.001, Figure 1). The presence of at least one high-volume transplant center in-state corresponded with greater waitlist access (Figure 2). Outcomes on the waitlist and at 1 and 3 years post-transplant did not differ by county CHS or presence of a high-volume in-state center.

*Conclusions: Children with liver disease in underprivileged areas have lesser access to the liver transplant waitlist and a higher death rate from liver disease. Greater distance to a transplant center is associated with lesser waitlist access. Further research is necessary to identify means by which to reduce disparities in waitlisting and facilitate receipt of care for patients in remote and underserved communities.

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