Low utilization of adult-to-adult LDLT in Western countries despite excellent outcomes: International multicenter analysis of the US, the UK, and Canada

Tommy Ivanics, David Wallace, Marco P.A.W. Claasen, Madhukar S. Patel, Rushin Brahmbhatt, Chaya Shwaartz, Andreas Prachalias, Parthi Srinivasan, Wayel Jassem, Nigel Heaton, Mark S. Cattral, Nazia Selzner, Anand Ghanekar, Gabriela Morgenshtern, Neil Mehta, Allan B. Massie, Jan van der Meulen, Dorry L. Segev, Gonzalo Sapisochin

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Background & Aims: Adult-to-adult living donor liver transplantation (LDLT) offers an opportunity to decrease the liver transplant waitlist and reduce waitlist mortality. We sought to compare donor and recipient characteristics and post-transplant outcomes after LDLT in the US, the UK, and Canada. Methods: This is a retrospective multicenter cohort-study of adults (≥18-years) who underwent primary LDLT between Jan-2008 and Dec-2018 from three national liver transplantation registries: United Network for Organ Sharing (US), National Health Service Blood and Transplantation (UK), and the Canadian Organ Replacement Registry (Canada). Patients undergoing retransplantation or multi-organ transplantation were excluded. Post-transplant survival was evaluated using the Kaplan-Meier method, and multivariable adjustments were performed using Cox proportional-hazards models with mixed-effect modeling. Results: A total of 2,954 living donor liver transplants were performed (US: n = 2,328; Canada: n = 529; UK: n = 97). Canada has maintained the highest proportion of LDLT utilization over time (proportion of LDLT in 2008 – US: 3.3%; Canada: 19.5%; UK: 1.7%; p <0.001 – in 2018 – US: 5.0%; Canada: 13.6%; UK: 0.4%; p <0.001). The 1-, 5-, and 10-year patient survival was 92.6%, 82.8%, and 70.0% in the US vs. 96.1%, 89.9%, and 82.2% in Canada vs. 91.4%, 85.4%, and 66.7% in the UK. After adjustment for characteristics of donors, recipients, transplant year, and treating transplant center as a random effect, all countries had a non-statistically significantly different mortality hazard post-LDLT (Ref US: Canada hazard ratio 0.53, 95% CI 0.28–1.01, p = 0.05; UK hazard ratio 1.09, 95% CI 0.59–2.02, p = 0.78). Conclusions: The use of LDLT has remained low in the US, the UK and Canada. Despite this, long-term survival is excellent. Continued efforts to increase LDLT utilization in these countries may be warranted due to the growing waitlist and differences in allocation that may disadvantage patients currently awaiting liver transplantation. Lay summary: This multicenter international comparative analysis of living donor liver transplantation in the United States, the United Kingdom, and Canada demonstrates that despite low use of the procedure, the long-term outcomes are excellent. In addition, the mortality risk is not statistically significantly different between the evaluated countries. However, the incidence and risk of retransplantation differs between the countries, being the highest in the United Kingdom and lowest in the United States.

Original languageEnglish (US)
Pages (from-to)1607-1618
Number of pages12
JournalJournal of Hepatology
Issue number6
StatePublished - Dec 2022
Externally publishedYes


  • Canada
  • CORR
  • LDLT
  • liver transplantation
  • living donor liver transplantation
  • STAR
  • UK
  • UNOS
  • US

ASJC Scopus subject areas

  • Hepatology


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