Anonymous living donation expands access and enhances equity in pediatric liver transplantation: A retrospective cohort study

Abstract

Living donor liver transplantation (LDLT) confers the best survival to children with end-stage liver disease, yet racial and socioeconomic barriers often preclude access to a biologically or emotionally related donor. Anonymous non-directed LDLT (A-LDLT), whereby altruistic strangers donate, could close this gap and diminish reliance on deceased-donor LT (DDLT), but its equity and efficacy have not been fully quantified. We therefore analyzed all 422 consecutive pediatric liver transplants at a large Canadian center from January 2005 to March 2023. In this retrospective cohort study, we compared recipient demographics, clinical characteristics, waitlist duration, and survival outcomes across A-LDLT (n=62), directed LDLT (Dir-LDLT; n=174), and DDLT (n=186) groups. Children who underwent A-LDLT were disproportionately Black or Indigenous, more often lived in single-parent households, and more frequently spoke a non-English primary language, indicating that anonymous donation reached socio-demographically disadvantaged groups. After adjusting for age, diagnosis, era, and PELD/MELD score, median wait time for cholestatic disease was 104 days with A-LDLT versus 138 days with DDLT—a 20% reduction—while operative complexity, vascular or biliary complication rates, and intensive-care stay were comparable to directed LDLT. One-, 5-, and 10- year patient survival rates after A-LDLT were 100%, 98% and 98% respectively, mirroring Dir-LDLT and exceeding DDLT (96%, 94%, 93%). Graft survival showed the same pattern. Integrating anonymous non-directed donors enlarges the living-donor pool, decreases time to transplantation for vulnerable children, and preserves the superior long-term outcomes achieved with living-donor organs. Embedding A-LDLT alongside DDLT can reduce disparities and enable timely, life-saving transplantation for children without directed donors while maintaining the advantages associated with living-donor grafts.