The path to liver transplantation for low MELD patients: A comparative analysis of deceased and living donor grafts in the perfusion technology era.

Patients with low MELD scores remain at substantial risk for waitlist removal. We investigated modern outcomes and graft utilization for low MELD patients undergoing liver transplant (LT) in the US. Adult LT recipients with low MELD scores (match MELD≤20) from 2022 to 2023 were identified from the UNOS database and stratified by receipt of a donation-after-circulatory-death (DCD), donation-after-brain-death (DBD), or living donor (LD) graft. Demographic and outcome data were compared. Of 5946 recipients, 21.7 ​% underwent DCD transplant and 15.7 ​% LDLT. Both LD and DCD recipients spent less time on waitlist compared to DBD recipients (LD 4.4, DCD 5.0 months vs. DBD 6.0 months, p ​< ​0.001). Only DCD grafts preserved with static-cold-storage (SCS) had lower 1-year graft survival rates. Male sex led to higher odds of DCD-LT, while female sex and diagnosis of malignancy or cholestatic disease increased odds of LDLT. Both LD and DCD LT should be nationally encouraged to increase LT access for low MELD patients.