Family planning and donor type: Unrecognized benefits of living donor liver transplantation?

Abstract

Pregnancy outcomes following liver transplant (LT) are largely favorable, with comparable live birth rates to nontransplant populations, though several maternal and perinatal risks are greater. These outcome data are largely derived from deceased donor recipients, and whether pregnancy outcomes differ by donor type has not been studied. Thus, Osman et al [1] conducted a systematic review and meta-analysis comparing outcomes in 806 post-LT pregnancies and found that gestational hypertension, gestational diabetes, and mode of delivery were similar by donor type. Likewise, fetal outcomes were similar, and though the pooled incidence of stillbirth was higher for living donors, the weak correlation coefficient did not support the clinical significance of this finding. The authors do note the limitations of these data, as studies that included both living and deceased donor recipients did not stratify data by donor type. While 6 studies contributed to this meta-analysis, only 2 studies provided pooled data among living donor LT recipients. Thus, there is a need for further research on this topic, including consideration of evolving transplant practices on post-LT pregnancy outcomes, such as reduced steroid use in living donor recipients, and the growing use of machine perfusion for deceased donors.As Osman and colleagues highlight, the number of reproductive-age women undergoing LT in the United States has nearly tripled since the late 1980s, [2] which likely relates to the rising incidence of metabolicdysfunction associated and alcohol-associated steatotic liver disease. [3,4] However, sex disparities persist in access to transplant, with women being more likely to die on the waitlist or become too sick for a transplant. [5] This disparity is due in part to reliance on the Model for End-stage Liver Disease (MELD) score for organ allocation, as the use of creatinine in this calculation underestimates the renal dysfunction in women. Women are also more likely to have organs declined due to short stature, as deceased donors more often derive from men, leading to size mismatch. While implementation of MELD 3.0 will provide an additional point for female sex, disparities are likely to persist for 5%-10% of the shortest