Living Donor Liver Transplantation: Impact of Access to Care

Living Donor Liver Transplantation: Impact on Access to Care

Summary of CME Lecture by Daniel Maluf, MD

1. Main Clinical Topics Discussed

• Current state of liver transplantation in the United States, with emphasis on the organ supply-demand gap
• The role of living donor liver transplantation (LDLT) in expanding access to care
• Challenges threatening the deceased donor organ supply (aging, obesity, NASH, alcohol-related liver disease)
• Institutional and regulatory factors influencing LDLT program development
• Comparative analysis of LDLT utilization in Western versus Eastern countries

2. Key Learning Points, Guidelines, and Recommendations

Organ Supply Challenges:

• Aging donor population, rising obesity, NASH, and alcohol-related liver disease are progressively degrading deceased donor organ quality
• Approximately 20% of potential donors have fatty liver disease; steatosis >60% typically precludes organ utilization
• Increasing use of alcohol post-COVID has compounded donor organ quality concerns
• Predictive modeling suggests a potential 48% decline in viable donor organs if trends in obesity and aging continue unchecked

Living Donor Liver Transplantation:

• LDLT remains underutilized in Western countries despite excellent outcomes comparable to Eastern programs
• Both right and left lobe donations have demonstrated strong outcomes; lobe selection is typically center-specific
• LDLT is particularly valuable for patients with MELD scores below 25–27 who are unlikely to receive a deceased donor organ in a timely manner
• LDLT programs are resource-intensive and require institutional commitment, experienced surgeons, hepatologists, and dedicated ICU support

Expanding the Donor Pool (Marginal/Extended Criteria Donors):

• Centers are increasingly accepting hepatitis B core-positive, hepatitis C-positive, older-age, fatty liver, and DCD (donation after cardiac death) organs
• Normothermic machine perfusion is an emerging but costly tool to improve utilization of marginal grafts

Regulatory Considerations:

• Recent UNOS/SRTR regulatory changes now evaluate transplant programs on four parameters: outcomes at 3 months, outcomes at 1 year, and waitlist mortality — potentially incentivizing LDLT program development

3. Specific Clinical Data and Statistics Cited

• 2021 U.S. waitlist: Approximately 11,000 patients listed for liver transplantation (down from >15,000 in 2013)
• Total liver transplants performed (2021): 9,236 — representing ~3.7% growth from 2020; projected ~4% growth annually
• Waitlist mortality:

- University of Maryland: ~10.5%

- National average: 12.5–14%

• Transplant within 1 year of listing:

- University of Maryland: ~51%

- National average: ~50%

• Living donor transplants:

- Declined sharply after the first donor death in 2001

- Reached a nadir around 2009

- 2021 volume: ~569 living donor liver transplants (~6% of all liver transplants)

- 2022 projected: ~600 LDLT cases — approaching but not yet surpassing the 2001 peak

• LDLT as proportion of total transplants in the U.S.: Grew from 3.3% (2008) to 5% (2018)
• LDLT decline noted in both the UK and Canada during the same 2008–2018 period
• NASH prevalence in the U.S.: 10–30% of liver biopsies; ~20% of donors have fatty liver disease
• Median MELD at transplant at University of Maryland: approximately 27–30

4. Practical Takeaways for Clinicians

• Identify LDLT candidates early: Patients with MELD <25–27, symptomatic complications (ascites, encephalopathy), or conditions limiting access to deceased donor organs (e.g., hepatocellular carcinoma within or beyond Milan criteria) should be evaluated for LDLT proactively
• LDLT program development is institution-specific: The decision to build or expand a LDLT program must account for local waitlist volume, waitlist mortality, transplant oncology caseload