*Purpose: Loneliness, defined by the National Academy of Medicine as “a subjective feeling of being isolated”, has recently emerged as a strong predictor of adverse health effects and is of increasing concern given the COVID-19 pandemic. We aimed to characterize loneliness in patients with end-stage liver disease (ESLD) awaiting liver transplantation (LT).

*Methods: We surveyed adult ambulatory cirrhosis patients awaiting LT at 7 U.S. sites during the COVID-19 pandemic (May2020-Jan2021) using the validated UCLA Three-Item Loneliness Scale by phone or video. Participants were asked to report if they felt: 1) they lack companionship, 2) left out, or 3) isolated using a 3-point scale (1=hardly ever, 2=some of the time, or 3=often). Participants were classified as “lonely” if they reported a score of ≥2 in at least 1 category. Frailty was assessed with the Liver Frailty Index (LFI); “frail”=LFI≥4.4. Logistic regression was used to associate loneliness and other factors.

*Results: Of 454 participants, 36% were female, median age was 60 years (IQR 53-64), median MELDNa was 14 (IQR 10-19), and 14% were frail. 181 (40%) met criteria for “lonely” in at least 1 category; 49 (11%) met criteria for “lonely” in all 3 categories. Compared to those who were not lonely, those who reported feeling lonely were younger (58 v. 61y) and more likely to be female (46% v. 29%), frail (19 v. 11%), or have hepatic encephalopathy (62 v. 50%). There were no differences by race/ethnicity, disease etiology, ascites, or MELDNa score. In univariable analysis, age (OR 0.97, 95% CI 0.96-0.99), female sex (OR 2.16, 95% CI 1.46-3.21), frailty (OR 1.88, 95% CI 1.09-3.2), and hepatic encephalopathy (OR 1.60, 95% CI 1.09-2.35) were associated with loneliness. After multivariable adjustment, younger age (OR 0.97, 95% CI 0.95-0.99), female sex (OR 1.95, 95% 1.30-2.90), and frailty (OR 1.5, 95% CI 1.2-1.96), remained significantly associated with loneliness.

*Conclusions: During the COVID-19 pandemic, loneliness was prevalent in patients with ESLD awaiting LT (40%). This is similar to rates reported in the general population (20-50%) during the pandemic, despite LT candidates being a select subgroup in which social support is a criterion for listing. In our cohort, younger age, female sex, and frailty were independently associated with loneliness. These data lay the foundation for future work investigating the extent to which loneliness impacts health outcomes in LT patients, as it does in the general population, and how targeting loneliness in interventions may facilitate improvements in frailty.

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