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So Shines a Good Deed in a Weary World

Heimbach, Julie K. MD1; Taner, Timucin MD, PhD1

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doi: 10.1097/TP.0000000000004066
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Since the first cases of living donor liver transplantation (LDLT) were described in the 1990s,1 LDLT has been cautiously and slowly adopted in the United States. Compared with Asia where LDLT comprises the majority of LT activity, for many years, LTs performed in the United States from LDs have remained only a fraction of those performed from deceased donors. The underlying reasons for this difference have been postulated to be multifactorial; in part related to availability and the presence of the infrastructure supporting the allocation of deceased donor organs in the United States, as well as heightened concern over donor risk. However, in the years leading up to the coronavirus disease 2019 pandemic (2016–2019), along with a rise in deceased donation, there has been a steady rise in the number of LDLTs performed in the United States.2 Concurrently, the interest in nondirected living liver donation has also been increasing, as evidenced by 2 recent large case series publications from North American centers.3,4 This is occurring in the setting of the widespread adoption of kidney paired donation and nondirected kidney donation. Although nondirected kidney donation has become well established, less is known about the adoption of nondirected liver donation in the United States.

In the current issue of Transplantation, Herbst et al5 analyze Scientific Registry of Transplant Recipients data from 2002 to 2020 specifically to identify trends in nondirected living liver donation (NDD) over time at the center level. The authors were able to identify nondirected donors, as they are categorized as a specific donor type “Non-Biological, Unrelated: Non-Directed Donation (Anonymous)” within Scientific Registry of Transplant Recipients data, and they matched each NDD liver recipient with a random subset of active waitlist candidates registered at their respective transplant centers, on the date of NDD transplantation, which allowed them to identify center-level differences between those selected for NDD versus remaining on the waitlist. This precise method of analysis can account for local differences in the characteristics of waitlisted candidates. The authors compared adult candidates and pediatric waitlisted candidates.

The most remarkable finding in the current analysis is the significant rise in the adoption of NDD that has occurred over just the past 3 y. Between 2002 and 2015, NDD comprised just 0.9% of all LDLTs with a total of 32 cases, whereas in 2020, despite the coronavirus disease 2019 pandemic, there were 58 NDDs, representing 12% of LDLTs performed that year. Also notable is that 35 centers reported performing at least 1 NDD during the study period, and although the authors describe this as “relatively few centers,” it is important to note that this represents nearly one-third of active LD centers and thus demonstrates widespread interest in adoption of NDD. The authors are also able to identify differences between donors who are more likely to be NDD versus directed LDs and differences in which recipients are most likely to receive NDDs. NDDs were slightly older (40 versus 35) and more likely to be college educated (82.3% versus 64.1%) compared with directed LDs, and they were more likely to be left lateral segment donors (31.8% versus 13.7%), though importantly 48% of NDDs were right lobe donors (compared with 62.7% of directed LDs). Also notable is that adult recipients of NDDs were more likely to be female and recipients of pediatric NDDs were more likely to be aged <2 y with a diagnosis of biliary atresia.

The authors argue that “there is an immediate need to develop a transparent and fair allocation system” for the use of NDDs. However, the careful analysis performed by the authors did not detect any racial bias in the utilization of NDDs and, in fact, did demonstrate that centers are already preferentially using NDDs for children aged <2 y and for adult female waitlist candidates, both of which have higher waitlist mortality. Thus, it seems that centers have already determined the most medically appropriate recipients, arguing against the need for increased federal oversight of the highly complex decision-making process that centers must consider donor and recipient size and anatomy, recipient characteristics such as acuity and likelihood of disease progression, local waitlist dynamics, and other even less predictable considerations such as donor preference for timing of surgery. The authors do note some knowledge gaps in the current analysis as the data set does not allow a determination between NDD and those donors who were unable to donate to their intended recipient and thus became NDDs or those who donated anonymously to a recipient whom they identified, nor can it be determined from the current data set the method by which the donors in the study population came forward. Thus, additional opportunities remain for further analysis of this truly remarkable group of individuals who, despite the challenges of the current pandemic, have increasingly made transplant possible for disadvantaged waitlisted patients. Hopefully, this current trend represents a tipping point, which signals not only broader acceptance of NDD in LT but also broader acceptance of LDLT in general.


1. Shakespeare W. The Merchant of Venice. Act V, Scene I. The Riverside Shakespeare. Houghton Mifflin; 1973.
2. US Department of Health and Human Services. Organ Procurement and Transplantation Network: National data. Available at Accessed November 12, 2021.
3. Flaig C, Humar A, Kirshner E, et al. Post-operative outcomes in anonymous living liver donors: what motivates individuals to donate to strangers. Clin Transpl. 2021;35:e14438.
4. Goldaracena N, Jung J, Aravinthan AD, et al. Donor outcomes in anonymous live liver donation. J Hepatol. 2019;71:951–959.
5. Herbst LR, Herrick-Reynolds K, Bowles Zeiser L, et al. The landscape of non-directed living liver donation in the United States. Transplantation. 2022;106:1600–1608.
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