Living Donor Liver Transplantation for Young Biliary Atresia Recipients Is Associated With Improved Outcomes in the Modern Era

Introduction: Biliary atresia (BA) is the most common indication for liver transplantation (LT) in children. We aimed to identify risk factors associated with survival in young patients with BA in the modern era.

Methods: We performed a retrospective analysis of BA patients aged < 2 years who received their first isolated LT with available data from the United Network for Organ Sharing database (01/2013-12/2022). Factors included in the multivariable Cox regression were graft type, race/ethnicity, insurance status, laboratory pediatric end-stage liver disease (PELD) score, history of portal vein thrombosis, and intensive care unit (ICU) status.

Results: 1226 BA LT recipients aged < 2 years were included, of whom 501 (40.9%) received deceased donor whole grafts (DDWG), 425 (34.7%) received deceased donor technical variants (DDTV), and 300 (24.5%) received living donor LT (LDLT). LDLT recipients were more likely to be white (p = 0.008) and have private insurance (p < 0.001). Multivariable analysis demonstrated that ICU status (hazard ratio [HR] = 3.23, 95% confidence interval [95% CI]: 1.72-6.08, p < 0.001) and DDTV graft vs. LDLT (HR = 3.03, 95% CI: 1.14-8.04, p = 0.03) were associated with an increased risk of patient mortality. Factors associated with an increased risk of graft loss included ICU status (HR = 1.89, 95% CI: 1.19-3.00, p = 0.007) and both DDWG (HR = 3.37, 95% CI: 1.65-6.87, p = 0.001) and DDTV (HR = 3.47, 95% CI: 1.69-7.14, p = 0.001) grafts vs. LDLT.

Conclusion: LDLT is associated with improved survival in patients with BA aged < 2 years; however, socioeconomic differences exist between LDLT and non-LDLT recipients. Efforts to promote early equitable referral to centers offering LDLT are essential for improving outcomes in young children with BA.