Interactions Between Donor and Recipient age in Liver Transplantation: Implications for Donor and Recipient Matching

As donor and recipient populations age, understanding how age mismatches affect liver transplantation (LT) outcomes is increasingly critical. This study examines trends in donor and recipient age and quantifies the impact of age mismatches on posttransplant outcomes.

We analyzed adult and pediatric LT recipients in the United States from 2011 to 2021. Donor and recipient characteristics, time trends, and allocation patterns were evaluated. Multivariable Cox models were used to assess the impact of donor age across recipient age strata on patient survival, graft survival, and death-censored graft survival.

The cohort included 57 142 LT recipients (median age 57 y; 64.4% male) and donors (mean age 41.1 y; 52.3% male). From 2011 to 2021, mean donor and recipient age increased modestly but significantly ( P  < 0.001). Five-year patient and graft survival declined with increasing donor age, particularly among younger recipients. In multivariable models, donor age >45 y was associated with increased risk of mortality and graft failure among recipients ≤35 y. In contrast, outcomes among recipients ≥65 y were largely unaffected by donor age. Death-censored analyses confirmed similar trends. Interaction analyses showed a statistically significant donor-recipient age interaction across all outcomes ( P  < 0.001).

Donor age has a disproportionate impact on younger LT recipients, whereas older recipients tolerate older grafts with less impact on survival. These findings support more age-conscious organ allocation strategies and provide actionable thresholds to guide clinical decision-making in donor-recipient matching.