Donor Type, social deprivation, and long‑term outcomes in pediatric liver transplantation: A 30‑year population‑based cohort

Background & Aims: Living donor liver transplantation (LDLT) reduces wait‑list mortality in children, but its long‑term advantages over deceased donor liver transplantation (DDLT) and how socioeconomic context shapes outcomes in a universal healthcare system remain uncertain. We compared long‑term outcomes after pediatric LDLT versus DDLT and evaluated modification by socioeconomic status (SES). Approach & Results: We linked clinical data for pediatric liver transplants in Ontario, Canada from 1991–2021 to provincial health administrative data, yielding 449 recipients (189 LDLT, 260 DDLT) who underwent first transplant. Over the 30-year period, LDLT recipients had superior patient and graft survival. After adjustment, DDLT was associated with a higher risk of mortality (adjusted hazard ratio aHR 2.1, 95% CI 1.0–4.3), graft failure (aHR 2.1, 95% CI 1.0–4.3), and chronic kidney disease (adjusted subdistribution HR 5.3, 95% CI 1.4–15.3), compared to LDLT. SES profoundly modified long-term outcomes: among DDLT recipients, lower neighborhood income and higher material deprivation were strongly linked to worse survival and increased graft loss. In contrast, LDLT moderated these socioeconomic disadvantages, with recipients showing comparable outcomes regardless of their SES (P for interaction <0.01). Conclusions: In this population-based cohort study, LDLT was associated with significantly better long-term patient and graft survival and a lower risk of chronic kidney disease compared to DDLT. Socioeconomic disadvantage negatively impacted outcomes primarily among DDLT recipients, highlighting the need to improve equitable access to LDLT and to strengthen targeted post-transplant support for socioeconomically vulnerable families.