*Purpose: We have previously shown that women on the liver transplant (LT) waitlist are at greater risk of hospitalization compared with men, but whether this impacts length of stay (LOS) in the peri-transplant setting is not known. We aimed to evaluate gender differences in post-LT LOS, an important surrogate of health care resource utilization post-LT.

*Methods: Using the UNOS/OPTN registry, we analyzed all US non-Status 1 adult LT recipients of deceased donor (DD) LT from 2008-2017, excluding those with MELD exception points. Poisson regression associated female gender with post-LT LOS, and logistic regression associated female gender with prolonged LOS (defined as >/= 20 days, the 75th percentile LOS cut-off in our cohort), and 3- and 12-month post-LT death.

*Results: Included were 28,281 DDLT recipients: 36% were female, 73% were non-Hispanic white. Median MELD at transplant was 28 [interquartile range (IQR) 22-36], 41% were hospitalized for ≥ 1-day pre-LT. Women were more likely to be hospitalized pre-LT than men (45% vs 40%, p<0.01), and were more likely to have prolonged (>10 days) pre-LT LOS (25% vs 20%, p<0.01). Post-LT, median LOS was 11 days (IQR 7-19); 24% had prolonged post-LT LOS (>= 20 days). Women were significantly more likely than men to have prolonged post-LT LOS (26% vs 23%, p<0.01). In univariable analysis, female gender was associated with longer post-LT LOS [incidence rate ratio (IRR) 1.09, 95% CI 1.09-1.10, p<0.01]. Prolonged pre-LT LOS (>10 days) and pre-LT ICU admissions were also independently associated with increased post–LT LOS (IRR 1.82, 95% CI 1.81-1.83, p<0.01, and IRR 1.91, 95% CI 1.90-1.93, p<0.01, respectively). In multivariable analysis, after adjustment for age, ethnicity, UNOS region, MELD, hepatic encephalopathy, and donor risk index, female gender remained independently associated with longer post-LT LOS (adjusted IRR 1.05, 95% CI 1.05-1.06, p<0.01). Women also experienced 12% increased adjusted odds of prolonged post-LT LOS (95% CI 1.05-1.20, p<0.01). Female gender was not associated with increased odds of death at 3- or 12 months. However, women with prolonged post-LT LOS had 2.1x adjusted odds of death at 1-year compared to women with shorter post-LT LOS (95% CI 1.84-2.50, p<0.01).

*Conclusions: Women who undergo DDLT in the US are more likely to have a prolonged post-LT LOS compared to men. Pre-LT LOS and pre-LT ICU admissions are strongly associated with post-LT LOS, and interestingly, women are also more likely to be hospitalized immediately pre-LT than men. Reducing the disproportionate burden of health care resource utilization by women compared with men in the peri-transplant period may require interventions to prevent hospitalizations pre-LT among women on the LT waitlist.

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