Meta-Analysis and Meta-Regression of Outcomes for Adult Living Donor Liver Transplantation Versus Deceased Donor Liver Transplantation

Arianna Barbetta; Mayada Aljehani; Michelle Kim; Christine Tien; Aaron Ahearn; Hannah Schilperoort; Linda Sher; Juliet Emamaullee


American Journal of Transplantation. 2021;21(7):2399-2412. 

In This Article

Abstract and Introduction


Prior single center or registry studies have shown that living donor liver transplantation (LDLT) decreases waitlist mortality and offers superior patient survival over deceased donor liver transplantation (DDLT). The aim of this study was to compare outcomes for adult LDLT and DDLT via systematic review. A meta-analysis was conducted to examine patient survival and graft survival, MELD, waiting time, technical complications, and postoperative infections. Out of 8600 abstracts, 19 international studies comparing adult LDLT and DDLT published between 1/2005 and 12/2017 were included. U.S. outcomes were analyzed using registry data. Overall, 4571 LDLT and 66,826 DDLT patients were examined. LDLT was associated with lower mortality at 1, 3, and 5 years posttransplant (5-year HR 0.87 [95% CI 0.81–0.93], p < .0001), similar graft survival, lower MELD at transplant (p < .04), shorter waiting time (p < .0001), and lower risk of rejection (p = .02), with a higher risk of biliary complications (OR 2.14, p < .0001). No differences were observed in rates of hepatic artery thrombosis. In meta-regression analysis, MELD difference was significantly associated with posttransplant survival (R 2 0.56, p = .02). In conclusion, LDLT is associated with improved patient survival, less waiting time, and lower MELD at LT, despite posing a higher risk of biliary complications that did not affect survival posttransplant.


With an ongoing shortage of deceased donor organs, living donor liver transplantation (LDLT) has emerged as an option to reduce waitlist mortality and address the growing disparity between organ supply and demand. As programs have gained experience, LDLT has been shown to result in equivalent, and in some cases, superior recipient survival and long-term outcomes compared to deceased donor liver transplantation (DDLT), even following risk-adjustment.[1,2] LDLT also conveys the benefits of decreased mortality on the waitlist, reduced waiting time, and potential for transplantation at a lower Model for End-Stage Liver Disease (MELD) score.[1,3]

Despite the potential for good outcomes, LDLT has constituted less than 5% of all liver transplants performed in the U.S. and <30% of all liver transplants in the Americas and Europe.[4,5] Concerns regarding donation-related complications and outcomes following living liver donation may have slowed the expansion of LDLT in the Western hemisphere. Long-term follow-up of the Adult-to-Adult Living Donor Liver Transplantation (A2ALL) cohort involving 740 donors showed that 40% experienced one or more complication, primarily Clavien-Dindo Grade 1 and 2, 95% of which resolved within the first-year postdonation.[6] In a recent Scientific Registry for Transplant Recipients (SRTR) analysis, among 105 non–directed living liver donors, only 15% experienced a postoperative complication or needed hospital readmission after donation, further demonstrating that the risk for living donors is generally low.[7]

In the early era of LDLT, technical complications including biliary stricture or leak, hepatic artery thrombosis (HAT), and small-for-size syndrome impacted posttransplant outcomes.[8–11] More recently, these early post-LDLT complications, while recognized to be higher than DDLT, have largely been mitigated by center experience and patient selection.[12–15] Generally, studies examining LDLT outcomes and complications, even in the contemporary era, have been limited to single center and/or national registry studies and have recognized limitations including differences in center experience, transplant recipient demographics, and duration of follow-up.[2,12,16]

Even in the contemporary era, the experience and outcomes of LDLT continue to be differentiated between lower volume, Western hemisphere countries and high-volume programs from the Middle East and Asia who rely on LDLT to overcome cultural and religious barriers to DDLT.[2,12,16,17] Previous meta-analyses have compared outcomes of LDLT and DDLT as it relates to biliary complications or hepatocellular carcinoma (HCC), focusing on patient survival and risk of disease recurrence.[18–22]

To date, a collective, global analysis of outcomes comparing LDLT and DDLT has not been completed. The aim of this study was to compare outcomes of LDLT to DDLT by performing a systematic review, meta-analysis, and meta-regression of patient survival, graft survival, and pretransplant and posttransplant outcomes.