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Background Chronic liver disease (CLD) carries major morbidity and mortality burdens in the UK, with CLD deaths increasing substantially in recent decades. Many individuals present for the first time in emergency medical settings with advanced disease, and 25% die within the first 60 days following index first emergency admission (FEA). Liver transplant (LT) is the only intervention with survival benefit in advanced CLD disease, however utilisation rates are very low. This analysis sought to quantify if socioeconomic status impacted access to LT.Methods National administrative hospital data were analyzed to construct a cohort of all adult patients in England with an FEA for CLD between 1 April 2012 and 31 March 2019. LT was ascertained in both hospital data and via linkage to NHS Blood and Transplant registry. Linkage to ONS death registrations enabled identification of death within first year following EA. Socioeconomic status was ascertained according to Index of Multiple Deprivation (IMD). Cumulative incidence (CI) of LT within the first 365 days following index EA was calculated, stratified by IMD quintile. To account for competing risk of death within the first year following index EA, a sub-distribution hazard model was utilised with death as a competing risk.Findings A total of 82, 402 individuals were included in the cohort. Within first year following index EA, only 0.7% of individuals underwent LT (n = 572, 95% CI 0.6% to 0.7%), whilst 37.6% died (n = 31, 212, 95% CI 37.2% to 37.9%). Over one third (n = 32, 649, 39.6%) of the cohort belonged to the most deprived (fifth) IMD quintile, with 22.0%, 16.3%, 12.4% and 9.1% belonging to the fourth through to first (least deprived) quintiles, respectively. There was marked difference in transplant use between socioeconomic strata, with cumulative incidence of LT varying across IMD quintiles ( figure 1, p < 0.001). This associated remained significant following adjustment for additional demographic factors, CLD aetiology and comorbid conditions. Those in the least deprived quintile were twice as likely to undergo LT (CI 1.0%, 95% CI 0.8%-1.2%) than those in the most deprived (CI 0.5%, 95% CI 0.4%-0.6%).Abstract O6 Figure 1Conclusions FEA for CLD is associated with very high mortality, but only a minority of individuals presenting via this clinical pathway undergo LT. There is strong association of socioeconomic status with probability of LT. Urgent action and further investigation is warranted to understand this stark inequality.