Heterogeneous effects of donor-related risk factors in 954 pediatric liver transplantations

Accepting a suitable donor for a child awaiting pediatric liver transplantation (pLT) is increasingly challenging. Donor-specific risk factors influence post-transplant outcomes, but evidence in pediatric patients remains inconsistent. We aimed to identify their influence on mortality and graft loss and investigate their dependence on recipient- and transplant-associated variables.

We analyzed 954 consecutive pLT cases (1983-2024). Patient and graft survival was analyzed and correlated to donor- and graft-specific variables by univariate and multivariate regression analyses, with a subgroup analysis for time era and indication for pLT.

Multivariate analysis showed that patient/graft survival was significantly impaired by elevated donor creatinine (hazard ratio [HR]: 1.951/1.728, p = 0.011/0.007) and cerebrovascular cause of death (HR: 1.691/3.797, p = 0.020/<0.001). ABO-incompatible pLT negatively correlated with patient survival (HR, 2.628; p = 0.002). Prolonged cold ischemic time (HR: 2.912, p = 0.005) and donor age >50 years (HR: 1.623, p = 0.042) impaired graft survival. Living donor liver transplantation (LDLT) showed improved patient survival (HR: 0.267, p < 0.001). The impact varied clearly by era and indication, as creatinine and AB0-incompatible pLT showed a significant impact only up to 2006, while higher donor age impaired graft survival in the current era. Cold ischemic time affected graft survival only in recipients with chronic cirrhotic liver disease.

Our results strengthen the position of LDLT in pLT in current times of organ shortages. Newly identified donor-specific risk factors as renal impairment alongside confirmed factors, like advanced donor age, prolonged CIT and cerebrovascular disease, help to identify marginal donors. Their impact is clearly dependent on recipient and transplant conditions, which underlines the importance of individually tailored donor profiles.