Toshifumi Yodoshi, Jennifer Stunguris, Maria De Angelis, Krista Van Roestel, Julia Hensley, Yaron Avitzur, Robert Bandsma, Nicola L. Jones, Binita M. Kamath, Mar Miserachs, Chantal Wiggins, Nazia Selzner, Anand Ghanekar, Mark S. Cattral, Blayne A. Sayed, Vicky L. Ng
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 nondirected 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 living donor liver transplantation (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 sociodemographically disadvantaged groups. After adjusting for age, diagnosis, era, and pediatric end-stage liver disease/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 directed living donor liver transplantation and exceeding DDLT (96%, 94%, and 93%). Graft survival showed the same pattern. Integrating anonymous nondirected 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.