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

Zhihao Li; Owen Jones; Christian T J Magyar; Marco P A W Claasen; Tommy Ivanics; Woo Jin Choi; Luckshi Rajendran; Erin Winter; Roxana Bucur; Nadia Rukavina; Elmar Jaeckel; Nazia Selzner; Blayne A Sayed; Anand Ghanekar; Mark Cattral; Gonzalo Sapisochin

doi:10.1097/SLA.0000000000006451

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

Ann Surg. 2026 Feb 1;283(2):326-334. doi: 10.1097/SLA.0000000000006451. Epub 2024 Jul 23.

Authors

Zhihao Li¹, Owen Jones¹, Christian T J Magyar^{1

2}, Marco P A W Claasen^{1

3}, Tommy Ivanics^{1

4

5}, Woo Jin Choi¹, Luckshi Rajendran¹, Erin Winter¹, Roxana Bucur¹, Nadia Rukavina¹, Elmar Jaeckel¹, Nazia Selzner¹, Blayne A Sayed¹, Anand Ghanekar¹, Mark Cattral¹, Gonzalo Sapisochin¹

Affiliations

¹ HBP & Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.
² Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
³ Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.
⁴ Department of Surgery, Henry Ford Hospital, Detroit, MI.
⁵ Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.

PMID: 39041223
DOI: 10.1097/SLA.0000000000006451

Abstract

Objective: 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.

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 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.

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 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.

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.

Keywords: intention-to-treat analysis; liver transplantation; living donor; organ donation; organ shortage; waitlist outcome.

MeSH terms

Adult
End Stage Liver Disease* / mortality
End Stage Liver Disease* / surgery
Female
Humans
Intention to Treat Analysis
Liver Transplantation* / mortality
Living Donors* / supply & distribution
Male
Middle Aged
Retrospective Studies
Survival Rate
Tissue and Organ Procurement*
Waiting Lists* / mortality