Regional variations of the living donor liver transplant experience in the United States

In this chapter we explore the state of live donor liver transplantation (LDLT) in the United States and the regional practice variations within this specialty. We begin with a brief overview of the history of LDLT and then discuss the current state. We show the expansion of the number of programs performing LDLT at significant volumes by region. There is confirmation of graft survival being positively affected by center volume in a recent era, however, graft survival is not significant. When looking at 90-day waitlist mortality, it appears that there is less mortality in centers with low-volume LDLT programs versus centers without an LDLT program in regions with low median MELD score at transplant. Additionally, there appears to be lower 90-day waitlist mortality in regions with higher median MELD score at transplant in centers that have high-volume LDLT programs as compared to centers without LDLT programs. This stresses the importance of having the capabilities for LDLT in different center settings. We also explore the regional differences in usage and outcomes of left lobe LDLT. We found that left lobe LDLT is concentrated in a few select regions as well as finding lower 1-year graft survival in left lobe LDLT in highly experienced centers. This may be due to these centers exploring the limits of the graft to recipient weight ratios as well as the challenging technical aspects of left lobe LDLT. We conclude with a robust discussion of the pathway forward to expansion of LDLT in the United States and offer a few unique perspectives on methods to achieve this.