Survival Outcomes of Liver Transplantation Amid Rising Recipient and Donor Risk Profiles.

BACKGROUND: Advances in liver transplantation (LT) have improved recipients' short-term survival. Whether similar gains extend to long-term outcomes remains unclear. METHODS: We conducted a retrospective analysis of adult, first-time LTs performed in the United States from 2002 to 2018, with follow-up through December 31, 2023. Patients were grouped into three eras: 2002-2007, 2008-2013, and 2014-2018. Exclusions were ABO-incompatible transplants, multivisceral or split grafts, and non-hepatocellular carcinoma malignancies. Survival was estimated with Kaplan-Meier methods; Cox proportional hazards models adjusted for primary indication, sex, Liver Transplant Risk Score (LTRS), and Donor Risk Index (DRI). RESULTS: Among 82,696 recipients, 23,656 underwent LT in 2002-2007, 29,355 in 2008-2013, and 29,685 in 2014-2018. Despite increasing LTRS and DRI over time, mortality was significantly lower in 2014-2018 than in earlier eras at 90 days, 1 year, and 5 years (all p < 0.001). Long-term survival improved across all LTRS strata except LTRS ≥ 7. Relative to 2002-2007, adjusted hazards for death were 0.89 (95% CI, 0.87-0.92; p < 0.001) in 2008-2013 and 0.67 (95% CI, 0.64-0.69; p < 0.001) in 2014-2018. CONCLUSIONS: Despite rising recipient complexity and broader use of higher-risk donors, both short- and long-term LT survival improved in the United States over the past two decades.