Living Donor Availability Improves Patient Survival in a North American Center: An Intention-to-treat Analysis

The aim of this study was to assess the impact of having a living donor on waitlist outcomes and overall survival through an intention-to-treat analysis.

Living-donor liver transplantation (LDLT) offers an alternative to deceased donation in the face of organ shortage. An as-treated analysis revealed that undergoing LDLT, compared with staying on the waiting list, is associated with improved survival, even at Model for End-stage Liver Disease-sodium (MELD-Na) score of 11.

Liver transplant candidates listed at the Ajmera Transplant Centre (2000-2021) were categorized as pLDLT (having a potential living donor) or pDDLT (without a living donor). Employing Cox proportional-hazard regression with time-dependent covariates, we evaluated pLDLT's impact on waitlist dropout and overall survival through a risk-adjusted analysis.

Of 4124 candidates, 984 (24%) had potential living donors. The pLDLT group experienced significantly lower overall waitlist dropouts (5.2% vs 34.4%, P <0.001) and mortality (3.8% vs 24.4%, P <0.001) compared with the pDDLT group. Possessing a living donor correlated with a 26% decline in the risk of waitlist dropout (adjusted hazard ratio=0.74, 95% CI: 0.55-0.99, P =0.042). The pLDLT group also demonstrated superior survival outcomes at 1 year (84.9% vs 80.1%), 5 years (77.6% vs 61.7%), and 10 years (65.6% vs 52.9%) from listing (log-rank P <0.001) with a 35% reduced risk of death (adjusted hazard ratio=0.65, 95% CI: 0.56-0.76, P <0.001). Moreover, the predicted hazard ratios consistently remained <1 across the MELD-Na range of 11 to 26.

Having a potential living donor significantly improves survival in end-stage liver disease patients, even with MELD-Na scores as low as 11. This emphasizes the need to promote awareness and adoption of LDLT in liver transplant programs worldwide.