Early Living Donor Liver Transplantation in Biliary Atresia: The Next Challenge Is Equity

Abbreviations

A‐LDLT

anonymous nondirected living donor liver transplantation

BA

biliary atresia

DDLT

deceased donor liver transplantation

LDLT

living donor liver transplantation

Dear Editor,

Wallace and colleagues should be congratulated for leveraging the Scientific Registry of Transplant Recipients to examine outcomes in 4733 children with biliary atresia. Their analysis demonstrates that low–Pediatric End‐Stage Liver Disease score living donor liver transplantation (LDLT) is associated with the most favorable outcomes, including significantly lower risks of graft loss and mortality after adjustment for relevant clinical factors [1]. These findings add to the growing body of evidence supporting LDLT in pediatric biliary atresia and move the field beyond the question of whether early LDLT confers a survival advantage toward a more pressing one: how can equitable access to this strategy be ensured?

Yet implementation is not simply a matter of expanding surgical capacity. Across North America, access to pediatric LDLT remains uneven and is closely linked to socioeconomic circumstances and caregiver resources [2]. The directed living donor pathway inherently depends on a family's ability to identify a suitable donor, navigate a complex evaluation process, and absorb the logistical and financial demands associated with donation. Single‐parent households, families with limited economic resources, those facing linguistic or cultural barriers, and socially isolated caregivers may face additional obstacles in accessing LDLT, consistent with broader concerns regarding inequitable access to living donation [3]. These disparities extend beyond biliary atresia. In a contemporary United Network for Organ Sharing analysis of children with cholestatic liver disease, non‐Hispanic White children were more likely to have private insurance, experienced shorter waitlist times, and received living donor grafts more frequently than non‐Hispanic Black or Hispanic children, while non‐Hispanic Black children experienced inferior post‐transplant survival and were more often transplanted at low‐volume centers [4]. Collectively, these findings suggest that access to LDLT is influenced not only by clinical need but also by the social and structural resources available to families. As evidence supporting early LDLT continues to accumulate, ensuring equitable access to living donor grafts will be essential to avoid widening existing disparities in outcomes.

The Toronto experience with anonymous nondirected living donor liver transplantation (A‐LDLT) offers one potential response to this challenge [5]. Among 422 consecutive pediatric liver transplant recipients, children undergoing A‐LDLT were disproportionately Black or Indigenous, more frequently from single‐parent households, and more likely to have a non‐English primary language, precisely the populations least likely to access directed living donation. Despite these social vulnerabilities, outcomes remained excellent, with 10‐year patient survival reaching 98%, comparable to directed LDLT and superior to deceased donor liver transplantation (DDLT), while wait times for cholestatic disease were reduced by nearly 20%. These findings suggest that A‐LDLT can expand access to the benefits of living donation without compromising outcomes. By reducing reliance on a recipient's immediate social network, this model may help decouple access to LDLT from the social and economic resources available to individual families.

For transplant programs, these findings suggest that equity must be addressed through deliberate structural interventions. Anonymous nondirected donor programs, culturally and linguistically tailored outreach, financial protections for living donors, and policies designed to expand access to LDLT all represent actionable opportunities. The economic argument is also compelling: LDLT has been associated with lower hospitalization costs and lower rates of post‐transplant dialysis than DDLT [3]. As evidence supporting early LDLT continues to accumulate, access to this strategy should be determined by clinical need rather than by race, socioeconomic circumstances, or family structure. The next challenge may therefore be less about demonstrating the superiority of early LDLT than about ensuring equitable access to its benefits.

Funding

The author has nothing to report.

Conflicts of Interest

The author declares no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.