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Donor–Recipient Relationship and Donor Educational Attainment in Living Liver Donation in the United States

Abstract

Living donor liver transplantation expands access to transplant and may reduce waitlist mortality among patients with end-stage liver disease, yet its use remains limited and unevenly distributed across donor subgroups. While prior national work has shown that living liver donation varies by donor–recipient relationship and demographic characteristics, the role of donor educational attainment in shaping these trends remains insufficiently studied. We examined whether growth in living liver donation in the United States from 2012 to 2022 differed jointly by donor–recipient relationship and donor educational attainment. We conducted a national registry study of living liver donors in the United States between January 1, 2012 and December 31, 2022 using Scientific Registry of Transplant Recipients data. The primary outcome was change in the annual number of living liver donors over time. Donors were stratified by donor–recipient relationship (biologically related versus unrelated), educational attainment (high school or less, technical school, bachelor’s/associate degree, and graduate degree), and age ( < 40 versus  ≥ 40 years). Negative binomial regression was used to estimate the incidence rate ratio for change in donor counts per 3-year increment. A total of 4,122 living liver donors were identified during the study period, including 2,845 biologically related donors and 1,277 unrelated donors. Growth in living liver donation was uneven across educational strata. Among biologically related donors, the greatest increase was observed in donors with graduate education (IRR 1.44, 95% CI 1.31–1.58), whereas among unrelated donors, the strongest rise also occurred in donors with graduate education (IRR 1.52, 95% CI 1.38–1.67). Lower-education donor groups demonstrated the smallest increase over time, with IRRs ranging from 1.00 to 1.15, compared with 1.31 to 1.62 in higher-education strata. Age-stratified analyses showed that the largest increase occurred among unrelated donors aged  < 40 years in the graduate education group (IRR 1.62, 95% CI 1.45–1.81). Living liver donation in the United States increased over the past decade, but the increase was concentrated in donor subgroups with higher educational attainment, especially among unrelated donors. These findings identify unequal growth in completed donation across donor subgroups, but they do not establish the mechanisms responsible for that pattern. Additional studies incorporating donor evaluation pathways, socioeconomic measures, and center- or region-level data are needed to clarify the processes underlying these differences.

Keywords: living liver donation; educational attainment; donor–recipient relationship; registry study; negative binomial regression; health equity
Copyright © 2025 Josh Levitsky and Andrew Martin. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.