Low utilization of adult-to-adult LDLT in Western countries despite excellent outcomes: International multicenter analysis of the US, the UK, and Canada

Tommy Ivanics, David Wallace, Marco P.A.W. Claasen, Madhukar S. Patel, Rushin Brahmbhatt, Chaya Shwaartz, Andreas Prachalias, Parthi Srinivasan, Wayel Jassem, Nigel Heaton, Mark S. Cattral, Nazia Selzner, Anand Ghanekar, Gabriela Morgenshtern, Neil Mehta, Allan B. Massie, Jan van der Meulen, Dorry L. Segev, Gonzalo Sapisochin*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Background & Aims: Adult-to-adult living donor liver transplantation (LDLT) offers an opportunity to decrease the liver transplant waitlist and reduce waitlist mortality. We sought to compare donor and recipient characteristics and post-transplant outcomes after LDLT in the US, the UK, and Canada. Methods: This is a retrospective multicenter cohort-study of adults (≥18-years) who underwent primary LDLT between Jan-2008 and Dec-2018 from three national liver transplantation registries: United Network for Organ Sharing (US), National Health Service Blood and Transplantation (UK), and the Canadian Organ Replacement Registry (Canada). Patients undergoing retransplantation or multi-organ transplantation were excluded. Post-transplant survival was evaluated using the Kaplan-Meier method, and multivariable adjustments were performed using Cox proportional-hazards models with mixed-effect modeling. Results: A total of 2,954 living donor liver transplants were performed (US: n = 2,328; Canada: n = 529; UK: n = 97). Canada has maintained the highest proportion of LDLT utilization over time (proportion of LDLT in 2008 – US: 3.3%; Canada: 19.5%; UK: 1.7%; p <0.001 – in 2018 – US: 5.0%; Canada: 13.6%; UK: 0.4%; p <0.001). The 1-, 5-, and 10-year patient survival was 92.6%, 82.8%, and 70.0% in the US vs. 96.1%, 89.9%, and 82.2% in Canada vs. 91.4%, 85.4%, and 66.7% in the UK. After adjustment for characteristics of donors, recipients, transplant year, and treating transplant center as a random effect, all countries had a non-statistically significantly different mortality hazard post-LDLT (Ref US: Canada hazard ratio 0.53, 95% CI 0.28–1.01, p = 0.05; UK hazard ratio 1.09, 95% CI 0.59–2.02, p = 0.78). Conclusions: The use of LDLT has remained low in the US, the UK and Canada. Despite this, long-term survival is excellent. Continued efforts to increase LDLT utilization in these countries may be warranted due to the growing waitlist and differences in allocation that may disadvantage patients currently awaiting liver transplantation. Lay summary: This multicenter international comparative analysis of living donor liver transplantation in the United States, the United Kingdom, and Canada demonstrates that despite low use of the procedure, the long-term outcomes are excellent. In addition, the mortality risk is not statistically significantly different between the evaluated countries. However, the incidence and risk of retransplantation differs between the countries, being the highest in the United Kingdom and lowest in the United States.

Original languageEnglish
Pages (from-to)1607-1618
Number of pages12
JournalJournal of Hepatology
Issue number6
Early online date25 Sep 2022
Publication statusPublished - 1 Dec 2022

Bibliographical note

Funding Information:
The data reported here have been supplied by UNOS, CORR, and NHSBT. The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as the official policy of or interpretation by CORR, NHSBT, or UNOS. The authors would like to thank all liver transplant centers for providing data to the registries, and to each registry for the collection and handling of all transplant information. Finally, the authors would like to thank Annabel Gravely for the creation of the graphical abstract.

Publisher Copyright:
© 2022 European Association for the Study of the Liver


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