*Purpose: Plans for distance based allocation in liver transplantation have raised concerns that patients listed in more rural Donor Service Areas (DSAs) will be disadvantaged because poor access to health care puts them at higher risk of death at the same MELD. We therefore examined whether there is an association between MELD at death on the wait list and DSA population.

*Methods: Clinical and demographic data were obtained from the Scientific Registry of Transplant Recipients (SRTR) for adults (>18 years old) listed and removed from the liver transplant waitlist from 2002 to 2017. Patients listed as status 1 patients, with exception points, inactive DSAs, and centers removing < three patients during that time were excluded. Estimated population size data was grouped by DSAs and was linked to the SRTR. Descriptive analysis was performed using linear regression.

*Results: Average MELD at removal for death by DSA ranged from 18.6 to 33.5, with median and mode of 25. One DSA did not have any patients removed for death during the study period. MELD at removal for death decreased by 0.03 points for each 100,000 increase in DSA population (p=0.02). To examine whether patients were being removed as too sick prior to actual death, we also looked at MELD at removal for too sick and found an increase of 0.02 points for each 100,000 increase in population (p=0.01). When all patients removed for either too sick or death, MELD at removal decreased by 0.03 points for each 100,000 increase in DSA population (p=0.02).

*Conclusions: Patients listed in low population DSAs die at higher MELDs than those in high population DSAs. However, they are removed as too sick at lower MELDs, and it is not clear whether this represents a true difference in patient risk of death or differences in center aggressiveness in recipient selection. When both too sick and death on the wait list are taken together, as presumably death follows soon after removal for too sick, MELD at removal is overall negatively correlated with population size. While specific patient factors such as distance to transplant center, socioeconomic status and primary insurance may influence risk of death at any particular MELD, there is no evidence that low population DSAs have lower death MELDs than high population DSAs, and in fact, the opposite appears to be the case.

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