Table 5:

LDLT Studies on High MELD Patients

Author/Year	Study Design	Study Population	Outcomes
Anouti et al 2024	Retrospective Cohort Registry Study	3558 LDLT recipients	An association of high MELD (>/=25) with lower graft survival was noted for recipients of LDLT and deceased brain-dead donor liver transplant (DBDLT). with no significant difference in 1- and 5-year graft survival between high-MELD LDLT compared with high-MELD DBDLT recipients.
Rosenthal et al 2024	Retrospective Cohort Registry Study	4495 LDLT recipients	LDLT led to superior patient survival at MELD <20 (adjusted HR 0.92; p = 0.024) and 20–24 (adjusted HR 0.70; p < 0.001), equivalent patient survival at MELD 25–29 (adjusted HR 0.97; p = 0.843), but worse graft survival at MELD =30. Sensitivity analysis exploring outcomes using a MELD score threshold of 30 or above noted LDLT had increased hazard of graft loss compared to DBDLT recipients. The effect of MELD >/=30 on graft survival was more pronounced in the MELD-Na era and among patients transplanted with NASH.
Roll et al 2022 (ERAS4OLT)	Systematic Review	35 studies included in final synthesis	MELD scores >25 alone is not a contraindication to LDLT though candidacy of these patients should be determined by a multidisciplinary team that takes into consideration the presence of comorbidities as well as donor factors that influence immediate graft function (e.g., donor age, graft size, steatosis, severity of portal hypertension, and venous drainage of the graft). They specifically noted that patients with MELD scores >35 should have an optimal graft (i.e., GRWR >.8, donor age<50-years, no steatosis, excellent venous drainage).
Jayant et al 2023 (CHALICE)	Systematic Review and Meta-analysis	10 studies with 2180 LDLT recipients	LDLT recipients and Low MELD-LDLT recipients had comparable mortality at 1, 3 and 5- years post-transplant with no differences observed in the rates of major morbidity, hepatic artery thrombosis, biliary complications, intraabdominal bleeding, wound infection and rejection; however, the High MELD -LDLT group had higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay.
Yun et al 2023	Retrospective Single Center	223 DDLT and 126 LDLT recipients	No statistical difference in graft survival between MELD >/= 35 LDLT and DDLT groups. Old age, acute on chronic liver failure, re-transplantation, preoperative intensive care unit stay and red blood cell (RBC) transfusion during the operation were risk factors for graft failure.
Matoba et al 2023	Retrospective Single Center	102 LDLT recipients	Comparable survival post LDLT among low MELD group: ≤20, moderate MELD group: 21-30, and high MELD group: ≥31.

Abbreviations: LDLT: Living Donor Liver Transplant, DDLT: Deceased Donor Liver Transplant, GRWR: Graft to Recipient Weight Ratio