Durable Clinical and Immunologic Advantage of Living Donor Liver Transplantation in Children

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Despite high survival in pediatric living donor liver transplantation (LDLT), only 10% of liver transplants in children in the United States are from living donors, reflecting reluctance to embrace this approach. In addition to optimal timing and graft quality, LDLT may offer immunologic benefit since most donors are haplo-identical parents. We sought to quantify the benefit of LDLT compared to deceased donor liver transplantation (DDLT) using granular clinical and immunologic outcomes over the long-term.


A retrospective cohort of children (age <18) surviving ≥1-year posttransplant was evaluated to determine the impact of donor type on graft survival and immunologic outcomes.


241 children (177 DDLT and 64 LDLT) were assessed. In multivariable analysis, LDLT was associated with a lower rate of acute cellular rejection (ACR) (HR 0.53; 95% confidence interval (CI): 0.29-0.98; p=0.04), a lower rate of chronic rejection (HR 0.12; 95% CI: 0.03-0.56; p=0.007), better graft survival on monotherapy immunosuppression at 3-years posttransplant (87.7% vs 46.7%; OR 7.41; 95% CI: 2.80-19.66; p<0.001), and a lower rate of graft loss (HR 0.29; 95% CI: 0.10-0.88; p=0.03). Graft type was not an independent predictor of posttransplant mortality (LDLT HR 0.57; 95% CI: 0.16-2.01; p=0.38). Maternal graft LDLT was associated with a lower rate of ACR (HR 0.13; 95% CI: 0.03-0.64; p=0.01) and posttransplant lymphoproliferative disorder (HR 0.04; 95% CI: 0.004-0.44; p=0.008) compared to paternal grafts.


This study demonstrates the potential benefit of LDLT, particularly with maternal grafts, for pediatric liver transplant recipients on multiple clinical parameters over long-term follow-up.

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