LIVING donor liver transplant (LDLT) remained underused in the US between 1999 and 2021, with persistent disparities in access despite a recovery in transplant rates after a decline between 2001 and 2009.
LDLT, in which part of a healthy person’s liver is donated to a recipient with end-stage liver disease, offers an alternative to deceased donor transplantation and has demonstrated favourable outcomes across Model for End-Stage Liver Disease (MELD) scores.
Researchers examined trends in LDLT by comparing transplant activity with both liver transplant waiting list data and liver-related deaths, using novel measures designed to capture patients who died before receiving a transplant or even reaching the waiting list.
The study analysed two national databases, including all US patients listed for liver transplantation between 1999 and 2021 and adults aged 25–64 years who died from cirrhosis or hepatocellular carcinoma. Investigators assessed the living donor liver transplant-to-listing ratio (LDLR), which measured the proportion of listed patients receiving LDLT, and the living donor liver transplant-to-death ratio (LDDR), which compared LDLT rates with deaths from end-stage liver disease.
During the study period, 5,087 patients underwent LDLT. Annual procedures increased from 124 to 361, although rates fell between 2001 and 2009 before rising again from 2009 onwards. Even with this recovery, the increase in liver-related deaths exceeded the growth in LDLT, limiting improvements in overall access.
Black patients consistently had the lowest LDLR and LDDR throughout the study, with no meaningful improvement over the two decades, indicating they remained less likely to receive a living donor liver transplant relative to both waiting list placement and liver-related deaths than other racial and ethnic groups.
Among women, LDLT rates increased after 2013 and exceeded those in men by 2021, but liver-related deaths also rose, meaning the increase in deaths outweighed gains in transplantation when measured using the LDDR.
The findings suggested that evaluating transplant waiting lists alone underestimated disparities because patients may die before referral, assessment or listing. Incorporating mortality data provided a broader picture of access to transplantation.
The authors noted that the rising burden of cirrhosis and hepatocellular carcinoma increased demand for liver transplantation, while LDLT remained an underused strategy that could improve access.
The researchers suggested that expanding LDLT programmes, reducing financial and insurance barriers, improving patient-provider communication and strengthening education and community awareness could help address inequities in transplant access. They also highlighted the value of community-focused transplant services and greater investigation into barriers affecting minority populations.
The study had several limitations. It relied on two separate public databases that could not be linked at an individual patient level, included only adults aged 25–64 years, and was limited by the available race, ethnicity and gender categories within those databases. The authors said further disaggregation of racial and ethnic groups, alongside the inclusion of additional populations, would be needed to better characterise disparities in living donor liver transplant access.
They also noted that more granular demographic data could help future studies identify disparities that may be obscured when broader population groups are analysed together.
Reference
Ng N et al. Racial and gender disparities in access to living donor liver transplantation between 1999-2021. J Liver Transplant.2026;DOI:10.1016/j.liver.2026.100364.
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