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

Li, Zhihao; Jones, Owen; Magyar, Christian T J; Claasen, Marco P A W; Ivanics, Tommy; Choi, Woo Jin; Rajendran, Luckshi; Winter, Erin; Bucur, Roxana; Rukavina, Nadia; Jaeckel, Elmar; Selzner, Nazia; Sayed, Blayne A; Ghanekar, Anand; Cattral, Mark; Sapisochin, Gonzalo (2024). Living Donor Availability Improves Patient Survival in a North American Center: An Intention-to-treat Analysis. (In Press). Annals of surgery Wolters Kluwer Health 10.1097/SLA.0000000000006451

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OBJECTIVE

Assess the impact of having a living donor on waitlist outcomes and overall survival through an intention-to-treat analysis.

BACKGROUND

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 to staying on the waiting list, is associated with improved survival, even at Model for End-stage Liver Disease-sodium (MELD-Na) score of 11.

METHODS

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.

RESULTS

Of 4,124 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 to 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- (84.9%vs. 80.1%), 5- (77.6%vs. 61.7%), and 10-year (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 below 1 across the MELD-Na range 11-26.

CONCLUSIONS

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.

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