Increasing Transplant Access for Low MELD Patients in the United States: Do We Still Need to Increase Adult Living Donor Liver Transplantation?

Abstract

Living donor liver transplantation (LDLT) offers an alternative for adults with Model for End-Stage Liver Disease (MELD) scores below 20, who often face prolonged wait times under urgency-based allocation. Although LDLT can reduce waitlist mortality and provide excellent transplant outcomes, deceased donor liver transplantation (DDLT), particularly from donation after circulatory death (DCD) donors, may similarly benefit patients with low MELD scores.Using the United Network for Organ Sharing database, adult candidates (age >17 years) listed or transplanted between 2010 and 2024 were evaluated. Annual volumes of LDLT and DDLT for low MELD patients and one-year cumulative incidence of DDLT or waitlist dropout among those with MELD-Na<20 (without exception scores) were analyzed. Recipient characteristics and graft survival were compared between patients receiving LDLT and DCD LT, including the impact of normothermic machine perfusion (NMP).Among 167 392 candidates, 5124 underwent LDLT. Annual LDLT volumes decreased by 14.8% from 2023 to 2024. Meanwhile, the number of DDLTs for MELD-Na<20 grew from 492 in 2010 to 2049 in 2024, with 46.0% of those cases coming from DCD donors in 2024. Over the study period, one-year cumulative incidence of DDLT increased for patients with MELD-Na<20. At two years post-transplant, graft survival was similar between LDLT and DCD LT with NMP (90.5% vs. 89.1%, p = 0.36).Deceased donor availability has substantially increased for patients with low MELD-Na, yielding graft survival comparable to LDLT. Further expansion of DCD LT could lower reliance on LDLT, thereby minimizing risks to healthy donors.

View details for DOI 10.1111/ctr.70513

View details for PubMedID 41869986