Living Donor Liver Transplant Is an Excellent Alternative for Many Patients. Here’s Why.
Best Survival Outcomes Achieved with Living Donor Liver Transplants, According to Recent Study
Patients in the United States who need a liver transplant (LT) often face a dilemma.
- Do they wait on the liver transplant list until a donation after brain death (DBD) liver becomes available?
- Do they accept a donation after circulatory death (DCD) donor if it becomes available sooner?
- Or do they look for a living donor (LD)?
This is an especially common dilemma for patients with a low Model for End-stage Liver Disease (MELD) score given the significant wait times associated with a low score. Indeed, the highest MELD scores—who are most ill—receive preference for sooner transplants using DBD livers.
For patients with lower MELD scores and/or those with liver cancer, DCD-LTs and LD-LTs may be viable life-saving options. But patients must weigh the benefits of these alternatives against their known risks. Namely, higher rates of ischemic cholangiopathy and biliary complications compared to DBD-LTs.
In recent years, use of both DCD-LTs and LD-LTs increased nationwide to provide access to more organs and mitigate the risk of waiting-list mortality during a period of ongoing organ scarcity.
This raises the question: how can hepatologists and transplant surgeons accurately convey the benefits and risks associated with DCD-LTs and LD-LTs to their patients as part of a shared decision-making process?
Results from a recent single-center study provide important data to help drive evidence-based decisions regarding all three of these donor options.

Raphael P.H. Meier, MD, PhD
Comparing Graft Survival Rates Among LT Types
Raphael P. H. Meier, MD, PhD, is a liver, kidney, and pancreas transplant and hepatobiliary surgeon and researcher at the University of Maryland School of Medicine. He led authorship of a recently published single-center, retrospective study that analyzed one- and five-year graft survival rates and rates of biliary complications in 3,483 liver transplant recipients between the years 1989 and 2019.
The study compared rates of graft survival in patients who received DCD-LTs (n=138), DBD-LTs (n=3,027) and LD-LTs (n=318). Survival rates shown in the table below.
Graft Survival Rates
One-year survival | Five-year survival | |
DCD-LTs | 88.6% | 70.0% |
DBD-LTs | 92.6% | 79.9% |
LD-LTs | 91.7% | 82.9% |
Patients who received DCD-LTs had a 1.7-fold adjusted risk of losing their graft compared to patients who received DBD-LTs (p=0.010) and a 1.3-fold adjusted risk compared to those with LD-LTs (p=0.403).
The survival rates across all three graft options match those previously reported in a similar analysis.
The study investigators also identified predictors of graft loss and patient death. These included:
- Age of the donor and recipient
- Time period during which the LT took place
- Presence of cholangiocarcinoma
- Cold ischemia time
Rates of Biliary Complications
DCD-LT and LD-LT outcomes can be compromised by biliary complications. For this reason, the study analyzed the occurrence of biliary complications in a subset of 414 LT recipients. Each donor type made up roughly one-third of the overall subset.
Rates of bile leaks, anastomotic stricture and non-anastomotic stricture follow.
Bile Leaks
- 10.1% with DCD-LTs
- 7.2% with DBD-LTs (p=0.402 vs DCD-LTs)
- 36.2% with LD-LTs (p=0.001 vs DCD-LTs)
Anastomotic Strictures
- 28.3% with DCD-LTs
- 18.1% with DBD-LTs (p=0.018 vs DCD-LTs)
- 43.5% with LD-LTs (p=0.006 vs DCD-LTs)
Non-Anastomotic Strictures
- 15.2% with DCD-LTs
- 1.4% with DBD-LTs (p=0.001 vs DCD-LTs)
- 4.3% with LD-LTs (p=0.005 vs DCD-LTs)
Although DCD-LTs and LD-LTs exhibited higher rates of biliary complications—bile leaks and anastomotic strictures—compared with DBD-LTs, both options led to excellent graft survival outcomes at one- and five-years. Overall, LTs without biliary complications resulted in better graft survival compared to any option with biliary complications.
LD-LTs Achieved the Best Survival Rates
Based on these data, the study authors concluded that both LD-LTs and DCD-LTs are viable alternatives to DBD-LT today and will likely become equivalent options in the future.
Of the three options, LD-LTs achieved the best one- and five-year graft survival rates.
Where there were no biliary complications, DCD-LTs also achieved excellent graft survival at one- and five-years. Advances in perfusion system technology further reduce the risk of biliary microcirculation damage and ischemia-reperfusion injury with DCD-LTs. The study authors look forward to increased use of normothermic preservation machines in the United States, which may help pave the way for DCD-LT to one day achieve equivalency with DBD-LT.
“The study describes comprehensively the benefits and risks of the three potential options to facilitate shared decision-making among physicians and patients,” said Dr. Meier. “In my practice, I can efficiently describe to my patients the benefits and risks of living donation versus the other options. Patients appreciate the evidence-based approach and data-driven decision making.”
Living Donor Transplants from a Leading US Center
Dr. Meier performs LD-LT and other transplant surgeries with his team at University of Maryland Medical Center (UMMC) in Baltimore. For more than 50 years, UMMC’s Division of Transplantation provides patients with world-class surgical and medical expertise.
Since 2020, the center performs more than an average of 305 organ transplants a year, giving recipients the opportunity to savor more time with the people they love and to enjoy a healthier quality of life. Dr. Meier and the transplant surgeons at UMMC utilize innovative techniques and demonstrate surgical excellence for all types of transplant surgeries, including LD-LT, DBD-LT and DCD-LT.
If you have a patient who may be a candidate for liver transplant, please refer them to the specialists at UMMC by calling 410-328-4030.
About Dr. Meier
Raphael P. H. Meier, MD, PhD is a liver, kidney and pancreas transplant and hepatobiliary surgeon and researcher at the University of Maryland School of Medicine. Dr. Meier is dedicated to providing excellent patient care, with a focus on helping those affected by end-stage liver and kidney diseases, as well as diabetic patients.
Dr. Meier earned his undergraduate degree and medical degree from the University of Geneva School of Medicine in Switzerland. He completed a general surgery residency at the University of Geneva Hospital, followed by a fellowship in abdominal transplant surgery at the University of California, San Francisco.
Dr. Meier maintains membership in key organizations, including the American Society of Transplant Surgeons and the American Society of Transplantation. He serves as a councilor of the International Xenotransplantation Association and as a committee member of the Basic and Translational Research Committee for the International Liver Transplantation Society.
Dr. Meier’s research interests encompass clinical transplant and hepatobiliary trials. He authored more than 80 scientific manuscripts and book chapters published in leading journals such as JAMA Medicine, Journal of Hepatology, American Journal of Transplantation and Transplantation.
Reference
Meier RPH, Kelly Y, Braun H, et al. Comparison of biliary complications rates after brain death, donation after circulatory death, and living-donor liver transplantation: A single-center cohort study. Transpl Int. 2022: 35:10855. doi: 10.3389/ti.2022.10855