Meta‐Analysis: Comparison of Living Versus Deceased Liver Transplantation for Primary Sclerosing Cholangitis

ABSTRACT Background and Aims Primary sclerosing cholangitis (PSC) is a rare disease that paradoxically accounts for 5%–15% of liver transplants (LT). The paucity of liver donors is boosting living donor LT (LDLT). We reviewed the literature regarding outcomes of LT in PSC, comparing LDLT with deceased donor LT (DDLT). Methods A systematic review with meta‐analysis was performed through a search on: PubMed, Web‐of‐Science, Scopus and Cochrane Central, from inception to December 2024. In total, 22 studies were included, enrolling 22,024 patients. Results Compared with LDLT, DDLT was associated with lower 1‐ (93.80% [95% CI 93.29–94.31] vs. 95.78% [95% CI 94.68–96.88]), 3‐ (88.81% [95% CI 88.14–89.48] vs. 93.23% [95% CI 91.85–94.61]) and 5‐year survival (85.18% [95% CI 84.43–85.92] vs. 91.54% [95% CI 91.01–93.07]), although it had no impact on graft survival. DDLT was associated with a higher risk of post‐LT sepsis (OR 3.68 [95% CI 1.02–13.26]), acute rejection (OR 1.75 [95% CI 1.12–2.73]) and PSC recurrence (OR 1.63 [95% CI 1.10–2.42]), but a lower risk of biliary complications (OR 0.29 [95% CI 0.11–0.78]). DDLT recipients were older (MD 4.26 years [95% CI 2.42–6.10]), with higher metabolic dysfunction, more advanced liver disease (higher MELD: MD 6.63 [95% CI 5.56–7.70]), but lower chances of having inflammatory bowel disease (OR 0.66 [95% CI 0.50–0.87]) or cholangiocarcinoma (OR 0.70 [95% CI 0.53–0.92]). DDLT donors were older (MD 2.46 years [95% CI 0.76–4.15]) and cold ischemia time was longer (MD 5.63 h [95% CI 3.18–8.08]). Conclusion In PSC, LDLT seems to be associated with higher post‐LT survival, compared with DDLT. This could be explained by earlier referral to LT with lower liver disease burden and better performance status; better graft quality; and shorter cold ischaemia time. PSC patients requiring LT should be encouraged to consider LDLT.