Background. For patients with Model for End-Stage Liver Disease (MELD) scores ≥35, deceased donor liver transplantation (DDLT) remains standard practice. However, organ shortages often delay transplantation and increase mortality. Living donor liver transplantation (LDLT) enables timely surgery but raises ethical/clinical concerns in high-MELD recipients. We aimed to compare perioperative outcomes, specifically renal recovery, between LDLT and DDLT in recipients with MELD scores ≥35 and identify factors associated with posttransplant prognosis. Methods. Perioperative outcomes, particularly renal recovery, were retrospectively analyzed in 712 patients with MELD scores ≥35 who underwent liver transplantation between 2000 and 2021, comparing LDLT and DDLT. After exclusions, 326 LDLT and 386 DDLT recipients were included, and 148 matched pairs were generated using propensity score matching. A subgroup analysis of patients undergoing preoperative renal replacement therapy (RRT) was also conducted. Results. LDLT was associated with significantly lower in-hospital mortality, despite longer operative times and comparable complication rates. Among patients requiring preoperative RRT, LDLT was associated with higher rates of renal recovery and significantly improved long-term graft survival, although overall survival did not differ between groups. In multivariate analysis, LDLT was not an independent predictor of survival; instead, age >65 y, retransplantation, and vasopressor use were significant mortality risk factors. Conclusions. In high-MELD recipients requiring preoperative RRT, LDLT provides meaningful advantages in renal recovery and graft survival. With appropriate donor selection and multidisciplinary perioperative management, LDLT represents a viable and ethically acceptable option even for high-risk recipients. Further studies are warranted to refine candidate selection.
KIM et al. (Mon,) studied this question.