Superior survival using living donors and donor-recipient matching using a novel living donor risk index

Abstract

The deceased-donor organ supply in the U.S. has not been able to keep pace with the increasing demand for liver transplantation. We examined national Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) data from 2002-2012 to assess whether living donor liver transplantation (LDLT) has surpassed deceased donor liver transplantation (DDLT) as a superior method of transplantation, and used donor and recipient characteristics to develop a risk score to optimize donor and recipient selection for LDLT. From 2002-2012, there were 2,103 LDLTs and 46,674 DDLTs that met the inclusion criteria. The unadjusted 3-year graft survival for DDLTs was 75.5% (95% confidence interval [CI]: 75.1-76.0%) compared with 78.9% (95% CI: 76.9-80.8%; P<0.001) for LDLTs that were performed at experienced centers (>15 LDLTs), with substantial improvement in LDLT graft survival over time. In multivariate models, LDLT recipients transplanted at experienced centers with either autoimmune hepatitis or cholestatic liver disease had significantly lower risks of graft failure (hazard ratio [HR]: 0.56, 95% CI: 0.37-0.84 and HR: 0.76, 95% CI: 0.63-0.92, respectively). An LDLT risk score that included both donor and recipient variables facilitated stratification of LDLT recipients into high, intermediate, and low-risk groups, with predicted 3-year graft survival ranging from >87% in the lowest risk group to <74% in the highest risk group.

Conclusion: Current posttransplant outcomes for LDLT are equivalent, if not superior, to DDLT when performed at experienced centers. An LDLT risk score can be used to optimize LDLT outcomes and provides objective selection criteria for donor selection in LDLT.

Figure 1

Figure 1a-MELD Era Post-Transplant Graft Survival Figure 1b-MELD Era Post-Transplant Patient Survival

Figure 1

Figure 1a-MELD Era Post-Transplant Graft Survival Figure 1b-MELD Era Post-Transplant Patient Survival

Figure 2

Figure 2a: Unadjusted Post-LDLT Graft Survival Rates Among All U.S. LDLT Recipients Stratified by Year of LDLT Figure 2b: Adjusted Post-LDLT Graft Survival Rates Among All U.S. LDLT Recipients Stratified by Year of LDLT

Figure 2

Figure 2a: Unadjusted Post-LDLT Graft Survival Rates Among All U.S. LDLT Recipients Stratified by Year of LDLT Figure 2b: Adjusted Post-LDLT Graft Survival Rates Among All U.S. LDLT Recipients Stratified by Year of LDLT