Sociodemographic Profile of Recipients and Donors in Crossover Living Donor Liver Transplantation: A Public Health Perspective from a High-Volume Center

Objectives: Liver paired exchange (LPE) is an innovative strategy for expanding the living donor pool in liver transplantation, enabling compatible transplants between otherwise incompatible donor-recipient pairs. Despite its growing global adoption, the sociodemographic characteristics of LPE populations remain largely unreported. This study aimed to comprehensively characterize the sociodemographic profile of all recipients and donors who underwent crossover living donor liver transplantation at a single high-volume center and to contextualize the findings within a public health framework.
Methods: This was a retrospective, cross-sectional, descriptive epidemiological study. All 393 crossover living donor liver trans-plants performed at the İnönü University Liver Transplant Institute (IULTI), Malatya, Türkiye, between October 2021 and May 2026 through the Banu Bedestenci Sönmez Liver Paired Exchange (BBS-LPE) system were included. Variables analyzed included recipient and donor age, sex, blood group, primary diagnosis, exchange chain size (2-way through 7-way), geographic origin, MELD/PELD score, and graft weight. Descriptive and comparative statistical analyses were performed using IBM SPSS Statistics v27.0 (IBM Corp., Armonk, NY, USA). The Mann-Whitney U and Chi-square tests were used for between-group comparisons.
Results: A total of 393 recipient-donor pairs completed LPE through 132 exchange events ranging from 2-way to 7-way chains, the latter representing a world-first. Annual LPE volume increased from 2 transplants in 2021 to 155 in 2025 (R²=0.94, p<0.001). Recipients comprised 64.9% males (mean age: 44.7±20.1 years); 14.8% were pediatric. The leading indications were cryptogenic cirrhosis (24.2%), HBV-related cirrhosis (13.5%), and HBV-associated hepatocellular carcinoma (8.4%). Male recipients were significantly older than females (46.4±19.4 vs. 41.5±21.1 years; p=0.042). Donors had a mean age of 30.7±8.0 years; 52.4% were under 30. Female donors constituted 41.2% of the total and were significantly more likely to donate to male recipients (p=0.039). Recipients originated from 68 Turkish prov-inces and 13 foreign countries; the southeastern Anatolian region contributed 35.9% of all domestic referrals. Şanlıurfa (8.4%), Gaziantep (7.6%), and Diyarbakır (6.1%) were the leading provinces of origin. International patients comprised 8.9% of the cohort (13 countries), with Syria as the most common country of origin.
Conclusion: This is the largest single-center sociodemographic analysis of an LPE population reported to date. Our data reveal pro-nounced geographic disparities, a consistent male predominance among recipients, a young donor population with a notable female contribution, and a broad disease spectrum spanning adult and pediatric indications. These findings underscore the critical public health role of high-volume LPE programs and highlight the need for targeted policies to address inequities in access to this life-saving modality. Sociodemographic profiling of LPE populations should become a standard component of transplant program reporting globally.

Keywords: Epidemiology, liver paired exchange, living donor liver transplantation, public health, sociodemographic profile, BBS-LPE system