A Changing Paradigm: The Swift Expansion of Adult Living Donor Liver Transplantation for MASH Cirrhosis.

Living donor liver transplantation (LDLT) provides a lifesaving option for patients with end-stage liver disease who may not be prioritized for deceased donor transplantation under the current model for end-stage liver disease (MELD)-based allocation system. Although prior studies have demonstrated a survival benefit for LDLT compared with remaining on the waitlist, limited data account for evolving liver disease epidemiology and donor characteristics in the United States. Methods: Using data from the Scientific Registry of Transplant Recipients/United Network of Organ Sharing (SRTR/UNOS), we conducted a retrospective cohort analysis of adult LDLT recipients and donors from 2000 to 2024. Trends were assessed using descriptive statistics and logistic regression. Results: A total of 7,686 LDLT recipients were identified. Indications included cholestatic liver disease (23%), hepatitis C virus (HCV) infection (16%), metabolic dysfunction-associated steatohepatitis (MASH) (15%), and alcohol-associated liver disease (ALD) (14%). MELD scores at LT varied by etiology, with higher scores in MASH and ALD. From 2000 to 2024, LDLT for MASH increased 5.4-fold (5.6% to 30.2%), while HCV declined sharply after 2014. LDLT for ALD remained stable despite increasing waitlist registrations. MASH recipients were more likely to receive grafts from younger related donors and less likely from older related donors or spouses compared with cholestatic liver disease. Conclusions: MASH is the fastest-growing indication for LDLT in the United States. These findings highlight limitations of MELD-based allocation and suggest a need to address donor eligibility barriers to improve equitable access to transplantation across liver disease etiologies.