Living-donor availability improves pediatric patient survival in a large North American center: An intention-to-treat analysis.

Background Although living donor liver transplantation (LDLT) is increasingly adopted for pediatric LT, there is limited data whether live donation extends benefits to patients from the time of listing. This study investigated the benefits of pediatric LDLT through an intention-to-treat analysis.Methods Pediatric candidates listed between 2001-2023 at a single Canadian center were categorized as pLDLT (with a potential live donor) or pDDLT (without a live donor). The primary endpoint was overall survival from the time of listing. The secondary endpoint involved the waitlist outcomes described by the probabilities of receiving LT or waitlist dropout.Results Among 474 candidates, 219 (46.2%) had potential live donors. The pLDLT group had a higher likelihood of receiving a LT (aHR 1.38, 95%CI:1.16-1.64) and lower risk of dying without a transplant (aHR 0.11, 95%CI:0.01-0.82) compared to the pDDLT group. Survival rates from the time of listing were significantly better in the pLDLT group at 1-(98.6% vs. 87.6%), 5-(96.6% vs. 84.4%), and 10-(96.6% vs. 83.1%) years. Having a potential live donor was linked to a 72% reduction in mortality risk (aHR 0.28, 95%CI:0.12-0.64). Although the number of patients listed annually increased over the study period, the waiting time for deceased donation shortened. This correlated with increased LDLT utilization, suggesting LDLT not only improved outcomes but shortened wait times even for pDDLT patients.Conclusion Having a potential live donor is associated with substantial survival benefit. Pediatric programs offering LDLT can expand the donor pool and decrease the waiting time for DDLT, supporting the argument for making LDLT a standard for pediatric candidates.