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Introduction: Living donor liver transplantation (LDLT) is a promising option for mitigating the deceased donor organ shortage and reducing waitlist mortality. Despite excellent outcomes and data supporting expanding candidate indications for LDLT, broader uptake throughout the United States has yet to occur. Methods: In response to this, the American Society of Transplantation hosted a virtual consensus conference (October 18–19, 2021), bringing together relevant experts with the aim of identifying barriers to broader implementation and making recommendations regarding strategies to address these barriers. In this report, we summarize the findings relevant to the selection and engagement of both the LDLT candidate and living donor. Utilizing a modified Delphi approach, barrier and strategy statements were developed, refined, and voted on for overall barrier importance and potential impact and feasibility of the strategy to address said barrier. Results: Barriers identified fell into three general categories: 1) awareness, acceptance, and engagement across patients (potential candidates and donors), providers, and institutions, 2) data gaps and lack of standardization in candidate and donor selection, and 3) data gaps regarding post‐living liver donation outcomes and resource needs. Conclusions: Strategies to address barriers included efforts toward education and engagement across populations, rigorous and collaborative research, and institutional commitment and resources. [ABSTRACT FROM AUTHOR]

Background: Each year, children die awaiting LT as the demand for grafts exceeds the available supply. Candidates with public health insurance are significantly less likely to undergo both deceased donor LT and D‐LLD LT. ND‐LLD is another option to gain access to a graft. The aim of this study was to evaluate if recipient insurance type is associated with likelihood of D‐LLD versus ND‐LLD LT. Methods: The SRTR/OPTN database was reviewed for pediatric LDLT performed between January 1, 2014 (Medicaid expansion era) and December 31, 2019 at centers that performed ≥1 ND‐LLD LDLT during the study period. A multivariable logistic regression was performed to assess relationship between type of living donor (directed vs. non‐directed) and recipient insurance. Results: Of 299 pediatric LDLT, 46 (15%) were from ND‐LLD performed at 18 transplant centers. Fifty‐nine percent of ND‐LLD recipients had public insurance in comparison to 40% of D‐LLD recipients (p =.02). Public insurance was associated with greater odds of ND‐LLD in comparison to D‐LLD upon multivariable logistic regression (OR 2.37, 95% CI 1.23–4.58, p =.01). Conclusions: ND‐LLD allows additional children to receive LTs and may help address some of the socioeconomic disparity in pediatric LDLT, but currently account for only a minority of LDLT and are only performed at a few institutions. Initiatives to improve access to both D‐LLD and ND‐LLD transplants are needed. [ABSTRACT FROM AUTHOR]

Background: There is some evidence in the literature to suggest that pre‐operative counselling improves pain scores postoperatively. However, it is unclear whether pre‐operative counselling of the donor improves immediate and short‐term outcomes after living liver donation. Objectives: This systematic review aimed to investigate the available quality of evidence (QOE) of pre‐operative counselling for living donors on short term outcomes, provide expert opinion, grade recommendations and identify relevant components for Enhanced Recovery after Surgery (ERAS) protocols. Data Sources: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. Methods: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Endpoints were defined by the WHOQOL‐BREF scale: physical health, psychological, social relationships, and environment. PROSPERO ID: CRD42021260677. Results: Screening of 452 records and full texts led to 12 articles matching inclusion criteria, of which one was a randomized controlled trial (RCT), and 11 were observational retrospective cohort studies. A total of 933 individuals undergoing donor hepatectomy were included, of whom only 90 received dedicated perioperative ERAS protocols. Donors that received pre‐operative counselling had fewer physical symptoms post donation, lower rates of fatigue, lower rates of pain, shorter recovery times and fewer unexpected medical problems, and less anxiety post donation. Female donors had higher affective and adverse effects scores, and 50% of donors reported adverse effects to analgesia that interfered with functional activity. Receiving information about analgesic options increased perception of care among donors. Conclusions: Providing comprehensive pre‐operative counselling to living liver donors is associated with improved short‐term outcomes after donation (QOE; moderate to low I Grade of Recommendation; Strong). [ABSTRACT FROM AUTHOR]

Understanding the association of social determinants of health (SDOH) with liver transplant listing and wait list outcomes can inform healthcare policy and interventions aimed at improving access to care. We analyzed the Scientific Registry of Transplant Recipients database merged with the Social Deprivation Index (SDI) to evaluate if area of residence is associated with Model for End-Stage Liver Disease incorporating sodium (MELD-NA) at time of wait list placement and outcomes following wait listing, and if this varied based on sociodemographic variables. Compared to candidates residing in areas of low SDI), those residing in areas of high SDI (most socioeconomic disadvantage) had 11% higher adjusted likelihood [aOR (95% CI)=1.11(CI 1.05,1.17)] of being listed for transplant with a MELD-NA score ≥30; this was not statistically significant when also adjusted for race/ethnicity [aOR=1.02(0.97,1.08)]. When stratified by race/ethnicity, residing in an area of high SDI was associated with a MELD-NA score ≥30 at time of wait listing among Hispanic White candidates (aOR=1.24, 95% CI: 1.04, 1.49). Candidates residing in areas of high SDI had 8% lower chance [aHR=0.92 (0.88,0.96)] of undergoing a liver transplant, 6% higher risk of death [aHR=1.06(1.002,1.13)], and 20% higher risk [aHR=1.20(1.13,1.28)] of removal on the wait list independent of race, ethnicity, insurance status, or sex. In the US, residence in areas of high socioeconomic disadvantage is significantly associated with higher MELD-NA at the time of wait listing among Hispanic White candidates. In addition, residence in areas of high socioeconomic disadvantage was associated with a higher risk of death or removal from the wait list and lower chances of receiving a liver transplant after wait list placement, particularly among Non-Hispanic White candidates and older candidates., (Copyright © 2024 American Association for the Study of Liver Diseases.)

The impact of social determinants of health on adult liver transplant recipient outcomes is not clear at a national level. Further understanding of the impact of social determinants of health on patient outcomes can inform effective, equitable health care delivery. Unadjusted and multivariable models were used to analyze the Scientific Registry of Transplant Recipients to evaluate the association between the Social Deprivation Index (SDI) based on the liver transplant recipient's residential location and patient and graft survival. We included adult recipients between January 1, 2008 and December 1, 2021. Patient and graft survival were lower in adults living in areas with deprivation scores above the median. Five-year patient and graft survival were 78.7% and 76.5%, respectively, in the cohort above median SDI compared to 80.5% and 78.3% below median SDI. Compared to the recipients in low-deprivation residential areas, recipients residing in the highest deprivation (SDI quintile = 5) cohort had 6% higher adjusted risk of mortality (adjusted hazard ratio = 1.06, 95% CI: 1.01-1.13) and 6% higher risk of graft failure (adjusted hazard ratio = 1.06, 95% CI: 1.001-1.11). The increased risks for recipients residing in more vulnerable residential areas were higher (adjusted hazard ratio = 1.11, 95% CI: 1.03-1.20 for both death and graft loss) following the first year after transplantation. Importantly, the overall risk for graft loss associated with SDI was not linear but instead accelerated above the median level of deprivation. In the United States, social determinants of health, as reflected by residential distress, significantly impacts 5-year patient and graft survival. The overall effect of residential deprivation modest, and importantly, results illustrate they are more strongly associated with longer-term follow-up and accelerate at higher deprivation levels. Further research is needed to evaluate effective interventions and policies to attenuate disparities in outcomes among recipients in highly disadvantaged areas., (Copyright © 2024 American Association for the Study of Liver Diseases.)

We surveyed living donor liver transplant programs in the United States to describe practices in the psychosocial evaluation of living donors focused on (1) composition of psychosocial team; (2) domains, workflow, and tools of the psychosocial assessment; (3) absolute and relative mental health-related contraindications to donation; and (4) postdonation psychosocial follow-up. We received 52 unique responses, representing 33 of 50 (66%) of active living donor liver transplant programs. Thirty-one (93.9%) provider teams included social workers, 22 (66.7%) psychiatrists, and 14 (42.4%) psychologists. Validated tools were rarely used, but domains assessed were consistent. Respondents rated active alcohol (93.8%), cocaine (96.8%), and opioid (96.8%) use disorder, as absolute contraindications to donation. Active suicidality (97%), self-injurious behavior (90.9%), eating disorders (87.9%), psychosis (84.8%), nonadherence (71.9%), and inability to cooperate with the evaluation team (78.1%) were absolute contraindications to donation. There were no statistically significant differences in absolute psychosocial contraindications to liver donation between geographical areas or between large and small programs. Programs conduct postdonation psychosocial follow-up (57.6%) or screening (39.4%), but routine follow-up of declined donors is rarely conducted (15.8%). Psychosocial evaluation of donor candidates is a multidisciplinary process. The structure of the psychosocial evaluation of donors is not uniform among programs though the domains assessed are consistent. Psychosocial contraindications to living liver donation vary among the transplant programs. Mental health follow-up of donor candidates is not standardized., (Copyright © 2023 American Association for the Study of Liver Diseases.)